hospital_name	last_updated_on	version	location_name	hospital_address	license_number|TN	type_2_npi	"To the best of its knowledge and belief, this hospital has included all applicable standard charge information in accordance with the requirements of 45 CFR 180.50, and the information encoded is true, accurate, and complete as of the date in the file. This hospital has included all payer-specific negotiated charges in dollars that can be expressed as a dollar amount. For payer-specific negotiated charges that cannot be expressed as a dollar amount in the machine-readable file or not knowable in advance, the hospital attests that the payer-specific negotiated charge is based on a contractual algorithm, percentage or formula that precludes the provision of a dollar amount and has provided all necessary information available to the hospital for the public to be able to derive the dollar amount, including, but not limited to, the specific fee schedule or components referenced in such percentage, algorithm or formula."	attester_name																																																																																																										
Sweetwater Hospital Association	7/1/2026	3.0.0	Sweetwater Hospital Association	"304 Wright Street, Sweetwater, TN 37874"	89	1912991076| 1205659711| 1629077532| 1558995399	TRUE	Ashley Shamblin																																																																																																										
description	code|1	code|1|type	code|2	code|2|type	code|3	code|3|type	modifiers	setting	drug_unit_of_measurement	drug_type_of_measurement	 standard_charge|gross 	 standard_charge|discounted_cash 	 standard_charge|min 	 standard_charge|max 	 standard_charge|Aetna|Commercial|negotiated_dollar 	standard_charge|Aetna|Commercial|negotiated_percentage	standard_charge|Aetna|Commercial|negotiated_algorithm	median_amount|Aetna|Commercial	10th_percentile|Aetna|Commercial	90th_percentile|Aetna|Commercial	count|Aetna|Commercial	standard_charge|Aetna|Commercial|methodology	additional_payer_notes|Aetna|Commercial	standard_charge|BlueCross BlueShield|Commercial|negotiated_dollar	standard_charge|BlueCross BlueShield|Commercial|negotiated_percentage	standard_charge|BlueCross BlueShield|Commercial|negotiated_algorithm	median_amount|BlueCross BlueShield|Commercial	10th_percentile|BlueCross BlueShield|Commercial	90th_percentile|BlueCross BlueShield|Commercial	count|BlueCross BlueShield|Commercial	standard_charge|BlueCross BlueShield|Commercial|methodology	additional_payer_notes|BlueCross BlueShield|Commercial	standard_charge|BlueCross BlueShield|Medicare|negotiated_dollar	standard_charge|BlueCross BlueShield|Medicare|negotiated_percentage	standard_charge|BlueCross BlueShield|Medicare|negotiated_algorithm	median_amount|BlueCross BlueShield|Medicare	10th_percentile|BlueCross BlueShield|Medicare	90th_percentile|BlueCross BlueShield|Medicare	count|BlueCross BlueShield|Medicare	standard_charge|BlueCross BlueShield|Medicare|methodology	additional_payer_notes|BlueCross BlueShield|Medicare	standard_charge|BlueCross BlueShield|Medicaid|negotiated_dollar	standard_charge|BlueCross BlueShield|Medicaid|negotiated_percentage	standard_charge|BlueCross BlueShield|Medicaid|negotiated_algorithm	median_amount|BlueCross BlueShield|Medicaid	10th_percentile|BlueCross BlueShield|Medicaid	90th_percentile|BlueCross BlueShield|Medicaid	count|BlueCross BlueShield|Medicaid	standard_charge|BlueCross BlueShield|Medicaid|methodology	additional_payer_notes|BlueCross BlueShield|Medicaid	standard_charge|Humana|Medicare|negotiated_dollar	standard_charge|Humana|Medicare|negotiated_percentage	standard_charge|Humana|Medicare|negotiated_algorithm	median_amount|Humana|Medicare	10th_percentile|Humana|Medicare	90th_percentile|Humana|Medicare	count|Humana|Medicare	standard_charge|Humana|Medicare|methodology	additional_payer_notes|Humana|Medicare	standard_charge|MultiPlan|Commercial|negotiated_dollar	standard_charge|MultiPlan|Commercial|negotiated_percentage	standard_charge|MultiPlan|Commercial|negotiated_algorithm	median_amount|MultiPlan|Commercial	10th_percentile|MultiPlan|Commercial	90th_percentile|MultiPlan|Commercial	count|MultiPlan|Commercial	standard_charge|MultiPlan|Commercial|methodology	additional_payer_notes|MultiPlan|Commercial	standard_charge|WellCare|Medicare|negotiated_dollar	standard_charge|Wellcare|Medicare|negotiated_percentage	standard_charge|Wellcare|Medicare|negotiated_algorithm	median_amount|WellCare|Medicare	10th_percentile|WellCare|Medicare	90th_percentile|WellCare|Medicare	count|WellCare|Medicare	standard_charge|WellCare|Medicare|methodology	additional_payer_notes|WellCare|Medicare	standard_charge|WellPoint|Medicaid|negotiated_dollar	standard_charge|WellPoint|Medicaid|negotiated_percentage	standard_charge|WellPoint|Medicaid|negotiated_algorithm	median_amount|WellPoint|Medicaid	10th_percentile|WellPoint|Medicaid	90th_percentile|WellPoint|Medicaid	count|WellPoint|Medicaid	standard_charge|WellPoint|Medicaid|methodology	additional_payer_notes|WellPoint|Medicaid	standard_charge|UHC|Commercial|negotiated_dollar	standard_charge|UHC|Commercial|negotiated_percentage	standard_charge|UHC|Commercial|negotiated_algorithm	median_amount|UHC|Commercial	10th_percentile|UHC|Commercial	90th_percentile|UHC|Commercial	count|UHC|Commercial	standard_charge|UHC|Commercial|methodology	additional_payer_notes|UHC|Commercial	standard_charge|UHC|Medicare|negotiated_dollar	standard_charge|UHC|Medicare|negotiated_percentage	standard_charge|UHC|Medicare|negotiated_algorithm	median_amount|UHC|Medicare	10th_percentile|UHC|Medicare	90th_percentile|UHC|Medicare	count|UHC|Medicare	standard_charge|UHC|Medicare|methodology	additional_payer_notes|UHC|Medicare	standard_charge|UHC|Medicaid|negotiated_dollar	standard_charge|UHC|Medicaid|negotiated_percentage	standard_charge|UHC|Medicaid|negotiated_algorithm	median_amount|UHC|Medicaid	10th_percentile|UHC|Medicaid	90th_percentile|UHC|Medicaid	count|UHC|Medicaid	standard_charge|UHC|Medicaid|methodology	additional_payer_notes|UHC|Medicaid	additional_generic_notes
12MM CANN SEAL #470380 *DISC SEE 470500*	272	RC						Both			63	28.35	28.35	56.7	40.95							Fee Schedule		46.62							Fee Schedule																													56.7							Fee Schedule																																															
"2,3-DINOR-11 BETA-PROS 24 HR UR 10109"	301	RC	84150	CPT				Both			741	333.45	30.07	666.9	30.07							Fee Schedule		41.77							Fee Schedule		43.02							Fee Schedule		41.77							Fee Schedule		41.77							Fee Schedule		666.9							Fee Schedule		48.04							Fee Schedule		38.85							Fee Schedule		41.77							Fee Schedule		48.04							Fee Schedule		38.85							Fee Schedule		
21-HYDROXYLASE ANTIBODY 39226	302	RC	83516	CPT				Both			258	116.1	10.25	232.2	10.25							Fee Schedule		12.81							Fee Schedule		11.88							Fee Schedule		11.53							Fee Schedule		11.53							Fee Schedule		232.2							Fee Schedule		13.26							Fee Schedule		10.72							Fee Schedule		11.53							Fee Schedule		13.26							Fee Schedule		10.72							Fee Schedule		
3 LUMEN EXTRACTOR PRO XL #M00547130	272	RC	C1726	CPT				Both			328.65	147.89	135.94	295.79	135.94							Fee Schedule		243.2							Fee Schedule																													295.79							Fee Schedule																																															
3D RENDERING I&R CT MRI US/ OTHER	352	RC	76376	CPT				Both			720.3	324.14	11.88	2478	220							Fee Schedule		11.88							Fee Schedule											94.38							Fee Schedule											648.27							Fee Schedule																				2478							Case Rate																				
3M BLOOD & FLUID WARMER #24250	271	RC						Both			32	14.4	14.4	28.8	20.8							Fee Schedule		23.68							Fee Schedule																													28.8							Fee Schedule																																															
5-HIAA  24-HR URINE 39625	301	RC	83497	CPT				Both			73.5	33.08	11.46	66.15	11.46							Fee Schedule		14.33							Fee Schedule		13.29							Fee Schedule		12.9							Fee Schedule		12.9							Fee Schedule		66.15							Fee Schedule		14.84							Fee Schedule		12							Fee Schedule		12.9							Fee Schedule		14.84							Fee Schedule		12							Fee Schedule		
5-HIAA  RANDOM URINE  1648	301	RC	83497	CPT				Both			36	16.2	11.46	32.4	11.46							Fee Schedule		14.33							Fee Schedule		13.29							Fee Schedule		12.9							Fee Schedule		12.9							Fee Schedule		32.4							Fee Schedule		14.84							Fee Schedule		12							Fee Schedule		12.9							Fee Schedule		14.84							Fee Schedule		12							Fee Schedule		
6 MIN WALK PULMONARY DIAGNOSTIC TEST	460	RC	94618	CPT				Both			321.71	144.77	8.92	318	200							Per Diem		238.07							Fee Schedule											8.92							Fee Schedule											289.54							Fee Schedule																				318							Per Diem																				
"76801 US UTERUS < 14 WKS, SGL / 1ST GEST"	402	RC	76801	CPT				Both			364	163.8	29.75	530	325							Per Diem		66.11							Fee Schedule											29.75							Fee Schedule											327.6							Fee Schedule																				530							Case Rate																				
"90471 IMMUNIZATION ADMIN, PROPH 1 VAC"	771	RC	90471	CPT				Both			16.5	7.43	4.47	14.85	10							Fee Schedule		12.21							Fee Schedule											4.47							Fee Schedule											14.85							Fee Schedule																																															
93922 - EXTREMITY STUDY	921	RC	93922	CPT				Both			321	144.45	35.49	800	507							Per Diem		237.54							Fee Schedule											35.49							Fee Schedule											288.9							Fee Schedule																				800							Per Diem																				
93923 - EXTREMITY STUDY	921	RC	93923	CPT				Both			395	177.75	67.09	800	507							Per Diem		292.3							Fee Schedule											67.09							Fee Schedule											355.5							Fee Schedule																				800							Per Diem																				
96374 IV PUSH-INITIAL-1 PER VISIT	260	RC	96374	CPT				Both			115.5	51.98	42	103.95	42							Fee Schedule		85.47							Fee Schedule											42.46							Fee Schedule											103.95							Fee Schedule																																															
99211 - OV E1 NURSE	519	RC	99211	CPT				Both			150	67.5	10.1	135	10.1							Fee Schedule		111							Fee Schedule											24.35							Fee Schedule											135							Fee Schedule																																															
99212 - OV E2 NURSE	519	RC	99212	CPT				Both			150	67.5	27.7	135	27.7							Fee Schedule		111							Fee Schedule											32.47							Fee Schedule											135							Fee Schedule																																															
A.O. ADAPTOR TRINKLE  05.001.250 ( DEPUY	270	RC						Both			5147.1	2316.2	2316.2	4632.39	3345.62							Fee Schedule		3808.85							Fee Schedule																													4632.39							Fee Schedule																																															
A/C JOINT BILAT	320	RC	73050	CPT				Both			315	141.75	19.13	318	20.55							Fee Schedule		24.22							Fee Schedule											19.13							Fee Schedule											283.5							Fee Schedule																				318							Per Diem																				
A2 RECEPTOR (PLA2R) ANTIBODY 39245	301	RC	83520	CPT				Both			765	344.25	12.43	688.5	12.43							Fee Schedule		17.27							Fee Schedule		17.79							Fee Schedule		17.27							Fee Schedule		17.27							Fee Schedule		688.5							Fee Schedule		19.86							Fee Schedule		16.06							Fee Schedule		17.27							Fee Schedule		19.86							Fee Schedule		16.06							Fee Schedule		
ABBOTT  SUPERA STENT S-60-150-120-P6	278	RC	C1876	CPT				Both			4050	1822.5	1822.5	3645		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	2997							Fee Schedule																													3645							Fee Schedule																																															
ABBOTT ARMADA  CATHETER A2020-040	272	RC	C1725	CPT				Both			459	206.55	93.3	413.1	93.3							Fee Schedule		339.66							Fee Schedule																													413.1							Fee Schedule																																															
ABBOTT ARMADA  CATHETER A2020-120	272	RC	C1725	CPT				Both			465	209.25	93.3	418.5	93.3							Fee Schedule		344.1							Fee Schedule																													418.5							Fee Schedule																																															
ABBOTT ARMADA  CATHETER A2020-200	272	RC	C1725	CPT				Both			488.25	219.71	93.3	439.43	93.3							Fee Schedule		361.31							Fee Schedule																													439.43							Fee Schedule																																															
ABBOTT ARMADA  CATHETER B1120-040	272	RC	C1725	CPT				Both			267	120.15	93.3	240.3	93.3							Fee Schedule		197.58							Fee Schedule																													240.3							Fee Schedule																																															
ABBOTT ARMADA  CATHETER B2120-020	272	RC	C1725	CPT				Both			264.6	119.07	93.3	238.14	93.3							Fee Schedule		195.8							Fee Schedule																													238.14							Fee Schedule																																															
ABBOTT ARMADA  CATHETER B2120-040	272	RC	C1725	CPT				Both			264.6	119.07	93.3	238.14	93.3							Fee Schedule		195.8							Fee Schedule																													238.14							Fee Schedule																																															
ABBOTT ARMADA  CATHETER B2120-060	272	RC	C1725	CPT				Both			519.75	233.89	93.3	467.78	93.3							Fee Schedule		384.62							Fee Schedule																													467.78							Fee Schedule																																															
ABBOTT ARMADA  CATHETER B2120-080	272	RC	C1725	CPT				Both			519.75	233.89	93.3	467.78	93.3							Fee Schedule		384.62							Fee Schedule																													467.78							Fee Schedule																																															
ABBOTT ARMADA  CATHETER B2140-020	272	RC	C1725	CPT				Both			519.75	233.89	93.3	467.78	93.3							Fee Schedule		384.62							Fee Schedule																													467.78							Fee Schedule																																															
ABBOTT ARMADA  CATHETER B2140-040	272	RC	C1725	CPT				Both			519.75	233.89	93.3	467.78	93.3							Fee Schedule		384.62							Fee Schedule																													467.78							Fee Schedule																																															
ABBOTT ARMADA  CATHETER B2140-060	272	RC	C1725	CPT				Both			519.75	233.89	93.3	467.78	93.3							Fee Schedule		384.62							Fee Schedule																													467.78							Fee Schedule																																															
ABBOTT ARMADA  CATHETER B2140-080	272	RC	C1725	CPT				Both			519.75	233.89	93.3	467.78	93.3							Fee Schedule		384.62							Fee Schedule																													467.78							Fee Schedule																																															
ABBOTT ARMADA LL CATHETER B2050-150	272	RC	C1725	CPT				Both			267	120.15	93.3	240.3	93.3							Fee Schedule		197.58							Fee Schedule																													240.3							Fee Schedule																																															
ABBOTT ARMADA LL CATHETER B2050-200	272	RC	C1725	CPT				Both			267	120.15	93.3	240.3	93.3							Fee Schedule		197.58							Fee Schedule																													240.3							Fee Schedule																																															
ABBOTT ARMADA LL CATHETER B2050-250	272	RC	C1725	CPT				Both			264.6	119.07	93.3	238.14	93.3							Fee Schedule		195.8							Fee Schedule																													238.14							Fee Schedule																																															
ABBOTT ARMADA LL CATHETER B2060-150	272	RC	C1725	CPT				Both			267	120.15	93.3	240.3	93.3							Fee Schedule		197.58							Fee Schedule																													240.3							Fee Schedule																																															
ABBOTT ARMADA LL CATHETER B2060-200	272	RC	C1725	CPT				Both			582.75	262.24	93.3	524.48	93.3							Fee Schedule		431.24							Fee Schedule																													524.48							Fee Schedule																																															
ABBOTT ARMADA LL CATHETER B2060-250	272	RC	C1725	CPT				Both			264.6	119.07	93.3	238.14	93.3							Fee Schedule		195.8							Fee Schedule																													238.14							Fee Schedule																																															
ABBOTT ARMADA LL CATHETER B2070-150	272	RC	C1725	CPT				Both			582.75	262.24	93.3	524.48	93.3							Fee Schedule		431.24							Fee Schedule																													524.48							Fee Schedule																																															
ABBOTT ARMADA LL CATHETER B2070-200	272	RC	C1725	CPT				Both			582.75	262.24	93.3	524.48	93.3							Fee Schedule		431.24							Fee Schedule																													524.48							Fee Schedule																																															
ABBOTT ARMADA PTA CATHETER 1013468-060	272	RC	C1725	CPT				Both			409.5	184.28	93.3	368.55	93.3							Fee Schedule		303.03							Fee Schedule																													368.55							Fee Schedule																																															
ABBOTT ARMADA PTA CATHETER 1013468-080	272	RC	C1725	CPT				Both			409.5	184.28	93.3	368.55	93.3							Fee Schedule		303.03							Fee Schedule																													368.55							Fee Schedule																																															
ABBOTT ARMADA PTA CATHETER 1013468-100	272	RC	C1725	CPT				Both			409.5	184.28	93.3	368.55	93.3							Fee Schedule		303.03							Fee Schedule																													368.55							Fee Schedule																																															
ABBOTT ARMADA PTA CATHETER 1013468-120	272	RC	C1725	CPT				Both			1023.75	460.69	93.3	921.38	93.3							Fee Schedule		757.58							Fee Schedule																													921.38							Fee Schedule																																															
ABBOTT ARMADA PTA CATHETER 1013468-150	272	RC	C1725	CPT				Both			409.5	184.28	93.3	368.55	93.3							Fee Schedule		303.03							Fee Schedule																													368.55							Fee Schedule																																															
ABBOTT ARMADA PTA CATHETER 1013468-200	272	RC	C1725	CPT				Both			409.5	184.28	93.3	368.55	93.3							Fee Schedule		303.03							Fee Schedule																													368.55							Fee Schedule																																															
ABBOTT ARMADA PTA CATHETER 1013469-040	272	RC	C1725	CPT				Both			708.75	318.94	93.3	637.88	93.3							Fee Schedule		524.48							Fee Schedule																													637.88							Fee Schedule																																															
ABBOTT ARMADA PTA CATHETER 1013469-060	272	RC	C1725	CPT				Both			409.5	184.28	93.3	368.55	93.3							Fee Schedule		303.03							Fee Schedule																													368.55							Fee Schedule																																															
ABBOTT ARMADA PTA CATHETER 1013469-080	272	RC	C1725	CPT				Both			409.5	184.28	93.3	368.55	93.3							Fee Schedule		303.03							Fee Schedule																													368.55							Fee Schedule																																															
ABBOTT ARMADA PTA CATHETER 1013469-120	272	RC	C1725	CPT				Both			1023.75	460.69	93.3	921.38	93.3							Fee Schedule		757.58							Fee Schedule																													921.38							Fee Schedule																																															
ABBOTT ARMADA PTA CATHETER 1013469-150	272	RC	C1725	CPT				Both			409.5	184.28	93.3	368.55	93.3							Fee Schedule		303.03							Fee Schedule																													368.55							Fee Schedule																																															
ABBOTT ARMADA PTA CATHETER 1013469-200	272	RC	C1725	CPT				Both			409.5	184.28	93.3	368.55	93.3							Fee Schedule		303.03							Fee Schedule																													368.55							Fee Schedule																																															
ABBOTT ARMADA PTA CATHETER 1013470-080	272	RC	C1725	CPT				Both			409.5	184.28	93.3	368.55	93.3							Fee Schedule		303.03							Fee Schedule																													368.55							Fee Schedule																																															
ABBOTT ARMADA PTA CATHETER 1013470-100	272	RC	C1725	CPT				Both			411	184.95	93.3	369.9	93.3							Fee Schedule		304.14							Fee Schedule																													369.9							Fee Schedule																																															
ABBOTT ARMADA PTA CATHETER 1013470-150	272	RC	C1725	CPT				Both			411	184.95	93.3	369.9	93.3							Fee Schedule		304.14							Fee Schedule																													369.9							Fee Schedule																																															
ABBOTT ARMADA PTA CATHETER 1013470-200	272	RC	C1725	CPT				Both			409.5	184.28	93.3	368.55	93.3							Fee Schedule		303.03							Fee Schedule																													368.55							Fee Schedule																																															
ABBOTT ARMADA PTA CATHETER A2025-040	272	RC	C1725	CPT				Both			1023.75	460.69	93.3	921.38	93.3							Fee Schedule		757.58							Fee Schedule																													921.38							Fee Schedule																																															
ABBOTT ARMADA PTA CATHETER A2025-060	272	RC	C1725	CPT				Both			1023.75	460.69	93.3	921.38	93.3							Fee Schedule		757.58							Fee Schedule																													921.38							Fee Schedule																																															
ABBOTT ARMADA PTA CATHETER A2025-120	272	RC	C1725	CPT				Both			488.25	219.71	93.3	439.43	93.3							Fee Schedule		361.31							Fee Schedule																													439.43							Fee Schedule																																															
ABBOTT ARMADA PTA CATHETER A2025-200	272	RC	C1725	CPT				Both			488.25	219.71	93.3	439.43	93.3							Fee Schedule		361.31							Fee Schedule																													439.43							Fee Schedule																																															
ABBOTT ARMADA PTA CATHETER B2015-040	272	RC	C1725	CPT				Both			1023.75	460.69	93.3	921.38	93.3							Fee Schedule		757.58							Fee Schedule																													921.38							Fee Schedule																																															
ABBOTT ARMADA PTA CATHETER B2015-080	272	RC	C1725	CPT				Both			1023.75	460.69	93.3	921.38	93.3							Fee Schedule		757.58							Fee Schedule																													921.38							Fee Schedule																																															
ABBOTT ARMADA PTA CATHETER B2015-120	272	RC	C1725	CPT				Both			1212.75	545.74	93.3	1091.48	93.3							Fee Schedule		897.44							Fee Schedule																													1091.48							Fee Schedule																																															
ABBOTT ARMADA PTA CATHETER B2020-040	272	RC	C1725	CPT				Both			1023.75	460.69	93.3	921.38	93.3							Fee Schedule		757.58							Fee Schedule																													921.38							Fee Schedule																																															
ABBOTT ARMADA PTA CATHETER B2020-060	272	RC	C1725	CPT				Both			1023.75	460.69	93.3	921.38	93.3							Fee Schedule		757.58							Fee Schedule																													921.38							Fee Schedule																																															
ABBOTT ARMADA PTA CATHETER B2020-080	272	RC	C1725	CPT				Both			1023.75	460.69	93.3	921.38	93.3							Fee Schedule		757.58							Fee Schedule																													921.38							Fee Schedule																																															
ABBOTT ARMADA PTA CATHETER B2020-120	272	RC	C1725	CPT				Both			1212.75	545.74	93.3	1091.48	93.3							Fee Schedule		897.44							Fee Schedule																													1091.48							Fee Schedule																																															
ABBOTT ARMADA PTA CATHETER B2020-200	272	RC	C1725	CPT				Both			1212.75	545.74	93.3	1091.48	93.3							Fee Schedule		897.44							Fee Schedule																													1091.48							Fee Schedule																																															
ABBOTT ARMADA PTA CATHETER B2025-040	272	RC	C1725	CPT				Both			1023.75	460.69	93.3	921.38	93.3							Fee Schedule		757.58							Fee Schedule																													921.38							Fee Schedule																																															
ABBOTT ARMADA PTA CATHETER B2025-060	272	RC	C1725	CPT				Both			1023.75	460.69	93.3	921.38	93.3							Fee Schedule		757.58							Fee Schedule																													921.38							Fee Schedule																																															
ABBOTT ARMADA PTA CATHETER B2025-080	272	RC	C1725	CPT				Both			1023.75	460.69	93.3	921.38	93.3							Fee Schedule		757.58							Fee Schedule																													921.38							Fee Schedule																																															
ABBOTT ARMADA PTA CATHETER B2030-040	272	RC	C1725	CPT				Both			1023.75	460.69	93.3	921.38	93.3							Fee Schedule		757.58							Fee Schedule																													921.38							Fee Schedule																																															
ABBOTT ARMADA PTA CATHETER B2030-060	272	RC	C1725	CPT				Both			1023.75	460.69	93.3	921.38	93.3							Fee Schedule		757.58							Fee Schedule																													921.38							Fee Schedule																																															
ABBOTT ARMADA PTA CATHETER B2030-080	272	RC	C1725	CPT				Both			1023.75	460.69	93.3	921.38	93.3							Fee Schedule		757.58							Fee Schedule																													921.38							Fee Schedule																																															
ABBOTT ARMADA PTA CATHETER B2030-120	272	RC	C1725	CPT				Both			1212.75	545.74	93.3	1091.48	93.3							Fee Schedule		897.44							Fee Schedule																													1091.48							Fee Schedule																																															
ABBOTT ARMADA PTA CATHETER B2030-200	272	RC	C1725	CPT				Both			1212.75	545.74	93.3	1091.48	93.3							Fee Schedule		897.44							Fee Schedule																													1091.48							Fee Schedule																																															
ABBOTT ARMADA PTA CATHETER B2040-040	272	RC	C1725	CPT				Both			267	120.15	93.3	240.3	93.3							Fee Schedule		197.58							Fee Schedule																													240.3							Fee Schedule																																															
ABBOTT ARMADA PTA CATHETER B2040-060	272	RC	C1725	CPT				Both			267	120.15	93.3	240.3	93.3							Fee Schedule		197.58							Fee Schedule																													240.3							Fee Schedule																																															
ABBOTT ARMADA PTA CATHETER B2040-080	272	RC	C1725	CPT				Both			264.6	119.07	93.3	238.14	93.3							Fee Schedule		195.8							Fee Schedule																													238.14							Fee Schedule																																															
ABBOTT ARMADA PTA CATHETER B2040-100	272	RC	C1725	CPT				Both			252	113.4	93.3	226.8	93.3							Fee Schedule		186.48							Fee Schedule																													226.8							Fee Schedule																																															
ABBOTT ARMADA PTA CATHETER B2040-120	272	RC	C1725	CPT				Both			252	113.4	93.3	226.8	93.3							Fee Schedule		186.48							Fee Schedule																													226.8							Fee Schedule																																															
ABBOTT ARMADA PTA CATHETER B2040-200	272	RC	C1725	CPT				Both			1212.75	545.74	93.3	1091.48	93.3							Fee Schedule		897.44							Fee Schedule																													1091.48							Fee Schedule																																															
ABBOTT ARMADA PTA CATHETER B2040-250	272	RC	C1725	CPT				Both			264.6	119.07	93.3	238.14	93.3							Fee Schedule		195.8							Fee Schedule																													238.14							Fee Schedule																																															
ABBOTT ARMADA PTA CATHETER B2050-020	272	RC	C1725	CPT				Both			519.75	233.89	93.3	467.78	93.3							Fee Schedule		384.62							Fee Schedule																													467.78							Fee Schedule																																															
ABBOTT ARMADA PTA CATHETER B2050-040	272	RC	C1725	CPT				Both			267	120.15	93.3	240.3	93.3							Fee Schedule		197.58							Fee Schedule																													240.3							Fee Schedule																																															
ABBOTT ARMADA PTA CATHETER B2050-060	272	RC	C1725	CPT				Both			267	120.15	93.3	240.3	93.3							Fee Schedule		197.58							Fee Schedule																													240.3							Fee Schedule																																															
ABBOTT ARMADA PTA CATHETER B2050-080	272	RC	C1725	CPT				Both			267	120.15	93.3	240.3	93.3							Fee Schedule		197.58							Fee Schedule																													240.3							Fee Schedule																																															
ABBOTT ARMADA PTA CATHETER B2050-100	272	RC	C1725	CPT				Both			264.6	119.07	93.3	238.14	93.3							Fee Schedule		195.8							Fee Schedule																													238.14							Fee Schedule																																															
ABBOTT ARMADA PTA CATHETER B2050-120	272	RC	C1725	CPT				Both			519.75	233.89	93.3	467.78	93.3							Fee Schedule		384.62							Fee Schedule																													467.78							Fee Schedule																																															
ABBOTT ARMADA PTA CATHETER B2060-020	272	RC	C1725	CPT				Both			519.75	233.89	93.3	467.78	93.3							Fee Schedule		384.62							Fee Schedule																													467.78							Fee Schedule																																															
ABBOTT ARMADA PTA CATHETER B2060-040	272	RC	C1725	CPT				Both			264.6	119.07	93.3	238.14	93.3							Fee Schedule		195.8							Fee Schedule																													238.14							Fee Schedule																																															
ABBOTT ARMADA PTA CATHETER B2060-060	272	RC	C1725	CPT				Both			267	120.15	93.3	240.3	93.3							Fee Schedule		197.58							Fee Schedule																													240.3							Fee Schedule																																															
ABBOTT ARMADA PTA CATHETER B2060-080	272	RC	C1725	CPT				Both			264.6	119.07	93.3	238.14	93.3							Fee Schedule		195.8							Fee Schedule																													238.14							Fee Schedule																																															
ABBOTT ARMADA PTA CATHETER B2060-100	272	RC	C1725	CPT				Both			519.75	233.89	93.3	467.78	93.3							Fee Schedule		384.62							Fee Schedule																													467.78							Fee Schedule																																															
ABBOTT ARMADA PTA CATHETER B2060-120	272	RC	C1725	CPT				Both			519.75	233.89	93.3	467.78	93.3							Fee Schedule		384.62							Fee Schedule																													467.78							Fee Schedule																																															
ABBOTT ARMADA PTA CATHETER B2070-020	272	RC	C1725	CPT				Both			519.75	233.89	93.3	467.78	93.3							Fee Schedule		384.62							Fee Schedule																													467.78							Fee Schedule																																															
ABBOTT ARMADA PTA CATHETER B2070-040	272	RC	C1725	CPT				Both			264.6	119.07	93.3	238.14	93.3							Fee Schedule		195.8							Fee Schedule																													238.14							Fee Schedule																																															
ABBOTT ARMADA PTA CATHETER B2070-060	272	RC	C1725	CPT				Both			519.75	233.89	93.3	467.78	93.3							Fee Schedule		384.62							Fee Schedule																													467.78							Fee Schedule																																															
ABBOTT ARMADA PTA CATHETER B2070-080	272	RC	C1725	CPT				Both			519.75	233.89	93.3	467.78	93.3							Fee Schedule		384.62							Fee Schedule																													467.78							Fee Schedule																																															
ABBOTT ARMADA PTA CATHETER B2070-100	272	RC	C1725	CPT				Both			267	120.15	93.3	240.3	93.3							Fee Schedule		197.58							Fee Schedule																													240.3							Fee Schedule																																															
ABBOTT ARMADA PTA CATHETER B2070-120	272	RC	C1725	CPT				Both			519.75	233.89	93.3	467.78	93.3							Fee Schedule		384.62							Fee Schedule																													467.78							Fee Schedule																																															
ABBOTT ARMADA PTA CATHETER B2080-020	272	RC	C1725	CPT				Both			519.75	233.89	93.3	467.78	93.3							Fee Schedule		384.62							Fee Schedule																													467.78							Fee Schedule																																															
ABBOTT ARMADA PTA CATHETER B2080-040	272	RC	C1725	CPT				Both			267	120.15	93.3	240.3	93.3							Fee Schedule		197.58							Fee Schedule																													240.3							Fee Schedule																																															
ABBOTT ARMADA PTA CATHETER B2080-060	272	RC	C1725	CPT				Both			519.75	233.89	93.3	467.78	93.3							Fee Schedule		384.62							Fee Schedule																													467.78							Fee Schedule																																															
ABBOTT ARMADA PTA CATHETER B2080-080	272	RC	C1725	CPT				Both			267	120.15	93.3	240.3	93.3							Fee Schedule		197.58							Fee Schedule																													240.3							Fee Schedule																																															
ABBOTT ARMADA PTA CATHETER B2090-020	272	RC	C1725	CPT				Both			519.75	233.89	93.3	467.78	93.3							Fee Schedule		384.62							Fee Schedule																													467.78							Fee Schedule																																															
ABBOTT ARMADA PTA CATHETER B2090-040	272	RC	C1725	CPT				Both			264.6	119.07	93.3	238.14	93.3							Fee Schedule		195.8							Fee Schedule																													238.14							Fee Schedule																																															
ABBOTT ARMADA PTA CATHETER B2090-060	272	RC	C1725	CPT				Both			519.75	233.89	93.3	467.78	93.3							Fee Schedule		384.62							Fee Schedule																													467.78							Fee Schedule																																															
ABBOTT ARMADA PTA CATHETER B2090-080	272	RC	C1725	CPT				Both			264.6	119.07	93.3	238.14	93.3							Fee Schedule		195.8							Fee Schedule																													238.14							Fee Schedule																																															
ABBOTT FLEX GUIDE WIRE 1012592	272	RC	C1769	CPT				Both			409.5	184.28	154.26	368.55	154.26							Fee Schedule		303.03							Fee Schedule																													368.55							Fee Schedule																																															
ABBOTT FLEX GUIDE WIRE 1012595	272	RC	C1769	CPT				Both			535.5	240.98	154.26	481.95	154.26							Fee Schedule		396.27							Fee Schedule																													481.95							Fee Schedule																																															
ABBOTT FOX PTA CATHETER 83173-02	272	RC	C1725	CPT				Both			708.75	318.94	93.3	637.88	93.3							Fee Schedule		524.48							Fee Schedule																													637.88							Fee Schedule																																															
ABBOTT FOX PTA CATHETER 83175-02	272	RC	C1725	CPT				Both			708.75	318.94	93.3	637.88	93.3							Fee Schedule		524.48							Fee Schedule																													637.88							Fee Schedule																																															
ABBOTT FOX PTA CATHETER 83976-02	272	RC	C1725	CPT				Both			1023.75	460.69	93.3	921.38	93.3							Fee Schedule		757.58							Fee Schedule																													921.38							Fee Schedule																																															
ABBOTT FOX PTA CATHETER 83977-02	272	RC	C1725	CPT				Both			1023.75	460.69	93.3	921.38	93.3							Fee Schedule		757.58							Fee Schedule																													921.38							Fee Schedule																																															
ABBOTT FOX PTA CATHETER 83978-02	272	RC	C1725	CPT				Both			1023.75	460.69	93.3	921.38	93.3							Fee Schedule		757.58							Fee Schedule																													921.38							Fee Schedule																																															
ABBOTT FOX PTA CATHETER 83980-02	272	RC	C1725	CPT				Both			708.75	318.94	93.3	637.88	93.3							Fee Schedule		524.48							Fee Schedule																													637.88							Fee Schedule																																															
ABBOTT FOX PTA CATHETER 83981-02	272	RC	C1725	CPT				Both			708.75	318.94	93.3	637.88	93.3							Fee Schedule		524.48							Fee Schedule																													637.88							Fee Schedule																																															
ABBOTT FOX PTA CATHETER 83982-02	272	RC	C1725	CPT				Both			1023.75	460.69	93.3	921.38	93.3							Fee Schedule		757.58							Fee Schedule																													921.38							Fee Schedule																																															
ABBOTT FOX PTA CATHETER 83983-02	272	RC	C1725	CPT				Both			1023.75	460.69	93.3	921.38	93.3							Fee Schedule		757.58							Fee Schedule																													921.38							Fee Schedule																																															
ABBOTT FOX PTA CATHETER 83984-02	272	RC	C1725	CPT				Both			1023.75	460.69	93.3	921.38	93.3							Fee Schedule		757.58							Fee Schedule																													921.38							Fee Schedule																																															
ABBOTT GUIDE WIRE 300CM  1013731	272	RC	C1769	CPT				Both			429	193.05	154.26	386.1	154.26							Fee Schedule		317.46							Fee Schedule																													386.1							Fee Schedule																																															
ABBOTT GUIDEWIRE 405063  (ST JUDE)	272	RC	C1769	CPT				Both			180	81	81	162	154.26							Fee Schedule		133.2							Fee Schedule																													162							Fee Schedule																																															
ABBOTT HI TORQUE COMMAND ES 2078175	272	RC	C1769	CPT				Both			78	35.1	35.1	154.26	154.26							Fee Schedule		57.72							Fee Schedule																													70.2							Fee Schedule																																															
ABBOTT HI TORQUE VERSACORE 1012068-07	272	RC	C1769	CPT				Both			204.75	92.14	92.14	184.28	154.26							Fee Schedule		151.52							Fee Schedule																													184.28							Fee Schedule																																															
ABBOTT OMNILINK ARMADA STENT 1012631-39	278	RC	C1876	CPT				Both			2205	992.25	992.25	1984.5		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1631.7							Fee Schedule																													1984.5							Fee Schedule																																															
ABBOTT SUPERA STENT S-50-060-120-P6	278	RC	C1876	CPT				Both			4252.5	1913.63	1913.63	3827.25		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	3146.85							Fee Schedule																													3827.25							Fee Schedule																																															
ABBOTT SUPERA STENT S-50-080-120-P6	278	RC	C1876	CPT				Both			4252.5	1913.63	1913.63	3827.25		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	3146.85							Fee Schedule																													3827.25							Fee Schedule																																															
ABBOTT SUPERA STENT S-50-100-120-P6	278	RC	C1876	CPT				Both			5040	2268	2268	4536		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	3729.6							Fee Schedule																													4536							Fee Schedule																																															
ABBOTT SUPERA STENT S-50-120-120-P6	278	RC	C1876	CPT				Both			4252.5	1913.63	1913.63	3827.25		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	3146.85							Fee Schedule																													3827.25							Fee Schedule																																															
ABBOTT SUPERA STENT S-55-040-120-P6	278	RC	C1876	CPT				Both			4252.5	1913.63	1913.63	3827.25		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	3146.85							Fee Schedule																													3827.25							Fee Schedule																																															
ABBOTT SUPERA STENT S-55-080-120-P6	278	RC	C1876	CPT				Both			4252.5	1913.63	1913.63	3827.25		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	3146.85							Fee Schedule																													3827.25							Fee Schedule																																															
ABBOTT SUPRA CORE 35 1002703-02	272	RC	C1769	CPT				Both			198	89.1	89.1	178.2	154.26							Fee Schedule		146.52							Fee Schedule																													178.2							Fee Schedule																																															
ABBOTT VASC PERCLOSE PROSTYLE 12773-03	272	RC	C1760	CPT				Both			849	382.05	114.86	764.1	114.86							Fee Schedule		628.26							Fee Schedule																													764.1							Fee Schedule																																															
ABBOTT VASC SUPERA STENT S-55-120-120-P6	278	RC	C1876	CPT				Both			4252.5	1913.63	1913.63	3827.25		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	3146.85							Fee Schedule																													3827.25							Fee Schedule																																															
ABBOTT VASC SUPERA STENT S-60-040-120-P6	278	RC	C1876	CPT				Both			4252.5	1913.63	1913.63	3827.25		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	3146.85							Fee Schedule																													3827.25							Fee Schedule																																															
ABBOTT VASC. ARMADA CATHETER A2030-040	272	RC	C1876	CPT				Both			456.75	205.54	205.54	1099.57	1099.57							Fee Schedule		338							Fee Schedule																													411.08							Fee Schedule																																															
ABBOTT VASC. ARMADA CATHETER A2030-060	272	RC	C1876	CPT				Both			456.75	205.54	205.54	1099.57	1099.57							Fee Schedule		338							Fee Schedule																													411.08							Fee Schedule																																															
ABBOTT VASC. ARMADA CATHETER A2030-080	272	RC	C1876	CPT				Both			456.75	205.54	205.54	1099.57	1099.57							Fee Schedule		338							Fee Schedule																													411.08							Fee Schedule																																															
ABBOTT VASC. ARMADA CATHETER A2030-120	272	RC	C1876	CPT				Both			489	220.05	220.05	1099.57	1099.57							Fee Schedule		361.86							Fee Schedule																													440.1							Fee Schedule																																															
ABBOTT VASC. ARMADA CATHETER A2030-200	272	RC	C1876	CPT				Both			488.25	219.71	219.71	1099.57	1099.57							Fee Schedule		361.31							Fee Schedule																													439.43							Fee Schedule																																															
ABBOTT VASC. PROCEED GUIDEWIRE 1030902	272	RC	C1769	CPT				Both			600	270	154.26	540	154.26							Fee Schedule		444							Fee Schedule																													540							Fee Schedule																																															
ABBOTT VASCU ABSOLUTE STENT 1012534-100	278	RC	C1876	CPT				Both			2205	992.25	992.25	1984.5		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1631.7							Fee Schedule																													1984.5							Fee Schedule																																															
ABBOTT VASCU ABSOLUTE STENT 1012534-40	278	RC	C1876	CPT				Both			2205	992.25	992.25	1984.5		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1631.7							Fee Schedule																													1984.5							Fee Schedule																																															
ABBOTT VASCU ABSOLUTE STENT 1012534-60	278	RC	C1876	CPT				Both			2205	992.25	992.25	1984.5		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1631.7							Fee Schedule																													1984.5							Fee Schedule																																															
ABBOTT VASCU ABSOLUTE STENT 1012534-80	278	RC	C1876	CPT				Both			2205	992.25	992.25	1984.5		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1631.7							Fee Schedule																													1984.5							Fee Schedule																																															
ABBOTT VASCU ABSOLUTE STENT 1012535-100	278	RC	C1876	CPT				Both			2205	992.25	992.25	1984.5		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1631.7							Fee Schedule																													1984.5							Fee Schedule																																															
ABBOTT VASCU ABSOLUTE STENT 1012535-40	278	RC	C1876	CPT				Both			2205	992.25	992.25	1984.5		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1631.7							Fee Schedule																													1984.5							Fee Schedule																																															
ABBOTT VASCU ABSOLUTE STENT 1012535-60	278	RC	C1876	CPT				Both			2205	992.25	992.25	1984.5		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1631.7							Fee Schedule																													1984.5							Fee Schedule																																															
ABBOTT VASCU ABSOLUTE STENT 1012535-80	278	RC	C1876	CPT				Both			2205	992.25	992.25	1984.5		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1631.7							Fee Schedule																													1984.5							Fee Schedule																																															
ABBOTT VASCU ABSOLUTE STENT 1012536-100	278	RC	C1876	CPT				Both			2205	992.25	992.25	1984.5		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1631.7							Fee Schedule																													1984.5							Fee Schedule																																															
ABBOTT VASCU ABSOLUTE STENT 1012536-40	278	RC	C1876	CPT				Both			2205	992.25	992.25	1984.5		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1631.7							Fee Schedule																													1984.5							Fee Schedule																																															
ABBOTT VASCU ABSOLUTE STENT 1012536-60	278	RC	C1876	CPT				Both			2205	992.25	992.25	1984.5		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1631.7							Fee Schedule																													1984.5							Fee Schedule																																															
ABBOTT VASCU ABSOLUTE STENT 1012536-80	278	RC	C1876	CPT				Both			2205	992.25	992.25	1984.5		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1631.7							Fee Schedule																													1984.5							Fee Schedule																																															
ABBOTT VASCU ABSOLUTE STENT 1012537-100	278	RC	C1876	CPT				Both			2205	992.25	992.25	1984.5		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1631.7							Fee Schedule																													1984.5							Fee Schedule																																															
ABBOTT VASCU ABSOLUTE STENT 1012537-40	278	RC	C1876	CPT				Both			2205	992.25	992.25	1984.5		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1631.7							Fee Schedule																													1984.5							Fee Schedule																																															
ABBOTT VASCU ABSOLUTE STENT 1012537-60	278	RC	C1876	CPT				Both			2205	992.25	992.25	1984.5		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1631.7							Fee Schedule																													1984.5							Fee Schedule																																															
ABBOTT VASCU ABSOLUTE STENT 1012537-80	278	RC	C1876	CPT				Both			2205	992.25	992.25	1984.5		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1631.7							Fee Schedule																													1984.5							Fee Schedule																																															
ABBOTT VASCU ABSOLUTE STENT 1012538-100	278	RC	C1876	CPT				Both			2250	1012.5	1012.5	2025		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1665							Fee Schedule																													2025							Fee Schedule																																															
ABBOTT VASCU ABSOLUTE STENT 1012538-40	278	RC	C1876	CPT				Both			2205	992.25	992.25	1984.5		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1631.7							Fee Schedule																													1984.5							Fee Schedule																																															
ABBOTT VASCU ABSOLUTE STENT 1012538-60	278	RC	C1876	CPT				Both			2205	992.25	992.25	1984.5		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1631.7							Fee Schedule																													1984.5							Fee Schedule																																															
ABBOTT VASCU ABSOLUTE STENT 1012538-80	278	RC	C1876	CPT				Both			2205	992.25	992.25	1984.5		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1631.7							Fee Schedule																													1984.5							Fee Schedule																																															
ABBOTT VASCU HERCULINK STENT 1011487-15	278	RC	C1876	CPT				Both			2205	992.25	992.25	1984.5		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1631.7							Fee Schedule																													1984.5							Fee Schedule																																															
ABBOTT VASCU HERCULINK STENT 1011487-18	278	RC	C1876	CPT				Both			2205	992.25	992.25	1984.5		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1631.7							Fee Schedule																													1984.5							Fee Schedule																																															
ABBOTT VASCU HERCULINK STENT 1011490-12	278	RC	C1876	CPT				Both			2205	992.25	992.25	1984.5		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1631.7							Fee Schedule																													1984.5							Fee Schedule																																															
ABBOTT VASCU HERCULINK STENT 1011490-12	278	RC	C1876	CPT				Both			2205	992.25	992.25	1984.5		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1631.7							Fee Schedule																													1984.5							Fee Schedule																																															
ABBOTT VASCU HERCULINK STENT 1011490-15	278	RC	C1876	CPT				Both			2205	992.25	992.25	1984.5		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1631.7							Fee Schedule																													1984.5							Fee Schedule																																															
ABBOTT VASCU HERCULINK STENT 1011490-18	278	RC	C1876	CPT				Both			2205	992.25	992.25	1984.5		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1631.7							Fee Schedule																													1984.5							Fee Schedule																																															
ABBOTT VASCU HERCULINK STENT 1011493-12	278	RC	C1876	CPT				Both			2205	992.25	992.25	1984.5		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1631.7							Fee Schedule																													1984.5							Fee Schedule																																															
ABBOTT VASCU HERCULINK STENT 1011493-15	278	RC	C1876	CPT				Both			2205	992.25	992.25	1984.5		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1631.7							Fee Schedule																													1984.5							Fee Schedule																																															
ABBOTT VASCU HERCULINK STENT 1011493-18	278	RC	C1876	CPT				Both			2205	992.25	992.25	1984.5		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1631.7							Fee Schedule																													1984.5							Fee Schedule																																															
ABBOTT VASCU HERCULINK STENT 1011496-12	278	RC	C1876	CPT				Both			2205	992.25	992.25	1984.5		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1631.7							Fee Schedule																													1984.5							Fee Schedule																																															
ABBOTT VASCU HERCULINK STENT 1011496-15	278	RC	C1876	CPT				Both			2205	992.25	992.25	1984.5		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1631.7							Fee Schedule																													1984.5							Fee Schedule																																															
ABBOTT VASCU HERCULINK STENT 1011496-18	278	RC	C1876	CPT				Both			2205	992.25	992.25	1984.5		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1631.7							Fee Schedule																													1984.5							Fee Schedule																																															
ABBOTT VASCU HERCULINK STENT 1011499-12	278	RC	C1876	CPT				Both			2205	992.25	992.25	1984.5		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1631.7							Fee Schedule																													1984.5							Fee Schedule																																															
ABBOTT VASCU HERCULINK STENT 1011499-15	278	RC	C1876	CPT				Both			2205	992.25	992.25	1984.5		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1631.7							Fee Schedule																													1984.5							Fee Schedule																																															
ABBOTT VASCU HERCULINK STENT 1011499-18	278	RC	C1876	CPT				Both			2205	992.25	992.25	1984.5		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1631.7							Fee Schedule																													1984.5							Fee Schedule																																															
ABBOTT VASCU OMNILINK STENT 1012623-59	278	RC	C1876	CPT				Both			2205	992.25	992.25	1984.5		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1631.7							Fee Schedule																													1984.5							Fee Schedule																																															
ABBOTT VASCU OMNILINK STENT 1012624-59	278	RC	C1876	CPT				Both			2205	992.25	992.25	1984.5		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1631.7							Fee Schedule																													1984.5							Fee Schedule																																															
ABBOTT VASCU OMNILINK STENT 1012626-39	278	RC	C1876	CPT				Both			2205	992.25	992.25	1984.5		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1631.7							Fee Schedule																													1984.5							Fee Schedule																																															
ABBOTT VASCU OMNILINK STENT 1012626-59	278	RC	C1876	CPT				Both			2205	992.25	992.25	1984.5		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1631.7							Fee Schedule																													1984.5							Fee Schedule																																															
ABBOTT VASCU OMNILINK STENT 1012629-12	278	RC	C1876	CPT				Both			2205	992.25	992.25	1984.5		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1631.7							Fee Schedule																													1984.5							Fee Schedule																																															
ABBOTT VASCU OMNILINK STENT 1012629-16	278	RC	C1876	CPT				Both			2205	992.25	992.25	1984.5		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1631.7							Fee Schedule																													1984.5							Fee Schedule																																															
ABBOTT VASCU OMNILINK STENT 1012629-19	278	RC	C1876	CPT				Both			2205	992.25	992.25	1984.5		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1631.7							Fee Schedule																													1984.5							Fee Schedule																																															
ABBOTT VASCU OMNILINK STENT 1012629-29	278	RC	C1876	CPT				Both			2205	992.25	992.25	1984.5		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1631.7							Fee Schedule																													1984.5							Fee Schedule																																															
ABBOTT VASCU OMNILINK STENT 1012629-39	278	RC	C1876	CPT				Both			2205	992.25	992.25	1984.5		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1631.7							Fee Schedule																													1984.5							Fee Schedule																																															
ABBOTT VASCU OMNILINK STENT 1012629-59	278	RC	C1876	CPT				Both			2205	992.25	992.25	1984.5		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1631.7							Fee Schedule																													1984.5							Fee Schedule																																															
ABBOTT VASCU OMNILINK STENT 1012630-12	278	RC	C1876	CPT				Both			2205	992.25	992.25	1984.5		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1631.7							Fee Schedule																													1984.5							Fee Schedule																																															
ABBOTT VASCU OMNILINK STENT 1012630-16	278	RC	C1876	CPT				Both			2205	992.25	992.25	1984.5		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1631.7							Fee Schedule																													1984.5							Fee Schedule																																															
ABBOTT VASCU OMNILINK STENT 1012630-19	278	RC	C1876	CPT				Both			2205	992.25	992.25	1984.5		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1631.7							Fee Schedule																													1984.5							Fee Schedule																																															
ABBOTT VASCU OMNILINK STENT 1012630-29	278	RC	C1876	CPT				Both			2205	992.25	992.25	1984.5		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1631.7							Fee Schedule																													1984.5							Fee Schedule																																															
ABBOTT VASCU OMNILINK STENT 1012630-39	278	RC	C1876	CPT				Both			2205	992.25	992.25	1984.5		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1631.7							Fee Schedule																													1984.5							Fee Schedule																																															
ABBOTT VASCU OMNILINK STENT 1012630-59	278	RC	C1876	CPT				Both			2205	992.25	992.25	1984.5		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1631.7							Fee Schedule																													1984.5							Fee Schedule																																															
ABBOTT VASCU OMNILINK STENT 1012631-19	278	RC	C1876	CPT				Both			2205	992.25	992.25	1984.5		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1631.7							Fee Schedule																													1984.5							Fee Schedule																																															
ABBOTT VASCU OMNILINK STENT 1012631-29	278	RC	C1876	CPT				Both			2205	992.25	992.25	1984.5		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1631.7							Fee Schedule																													1984.5							Fee Schedule																																															
ABBOTT VASCU OMNILINK STENT 1012631-59	278	RC	C1876	CPT				Both			2205	992.25	992.25	1984.5		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1631.7							Fee Schedule																													1984.5							Fee Schedule																																															
ABBOTT VASCU OMNILINK STENT 1012632-19	278	RC	C1876	CPT				Both			2205	992.25	992.25	1984.5		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1631.7							Fee Schedule																													1984.5							Fee Schedule																																															
ABBOTT VASCU OMNILINK STENT 1012632-29	278	RC	C1876	CPT				Both			2205	992.25	992.25	1984.5		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1631.7							Fee Schedule																													1984.5							Fee Schedule																																															
ABBOTT VASCU OMNILINK STENT 1012632-39	278	RC	C1876	CPT				Both			2205	992.25	992.25	1984.5		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1631.7							Fee Schedule																													1984.5							Fee Schedule																																															
ABBOTT VASCU OMNILINK STENT 1012632-59	278	RC	C1876	CPT				Both			2205	992.25	992.25	1984.5		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1631.7							Fee Schedule																													1984.5							Fee Schedule																																															
ABBOTT VASCU OMNILINK STENT 1012632-59	278	RC	C1876	CPT				Both			2205	992.25	992.25	1984.5		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1631.7							Fee Schedule																													1984.5							Fee Schedule																																															
ABBOTT VASCU OMNILINK STENT 1012633-19	278	RC	C1876	CPT				Both			2205	992.25	992.25	1984.5		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1631.7							Fee Schedule																													1984.5							Fee Schedule																																															
ABBOTT VASCU OMNILINK STENT 1012633-29	278	RC	C1876	CPT				Both			2205	992.25	992.25	1984.5		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1631.7							Fee Schedule																													1984.5							Fee Schedule																																															
ABBOTT VASCU OMNILINK STENT 1012633-39	278	RC	C1876	CPT				Both			2205	992.25	992.25	1984.5		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1631.7							Fee Schedule																													1984.5							Fee Schedule																																															
ABBOTT VASCU OMNILINK STENT 1012633-59	278	RC	C1876	CPT				Both			2205	992.25	992.25	1984.5		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1631.7							Fee Schedule																													1984.5							Fee Schedule																																															
ABBOTT VASCULAR ARMADA STENT A2040-040	278	RC	C1876	CPT				Both			456.75	205.54	205.54	411.08		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	338							Fee Schedule																													411.08							Fee Schedule																																															
ABBOTT VASCULAR ARMADA STENT A2040-080	278	RC	C1876	CPT				Both			459	206.55	206.55	413.1		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	339.66							Fee Schedule																													413.1							Fee Schedule																																															
ABBOTT VASCULAR ARMADA STENT A2040-200	278	RC	C1876	CPT				Both			488.25	219.71	219.71	439.43		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	361.31							Fee Schedule																													439.43							Fee Schedule																																															
ABBOTT VASCULAR ARMADA STENT B2060-040	278	RC	C1876	CPT				Both			488.25	219.71	219.71	439.43		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	361.31							Fee Schedule																													439.43							Fee Schedule																																															
ABBOTT VASCULAR GUIDEWIRE 1002703	272	RC	C1769	CPT				Both			189	85.05	85.05	170.1	154.26							Fee Schedule		139.86							Fee Schedule																													170.1							Fee Schedule																																															
ABBOTT VASCULAR GUIDEWIRE 1003282	272	RC	C1769	CPT				Both			189	85.05	85.05	170.1	154.26							Fee Schedule		139.86							Fee Schedule																													170.1							Fee Schedule																																															
ABBOTT VASCULAR GUIDEWIRE 1005203	272	RC	C1769	CPT				Both			189	85.05	85.05	170.1	154.26							Fee Schedule		139.86							Fee Schedule																													170.1							Fee Schedule																																															
ABBOTT VASCULAR GUIDEWIRE 1005206	272	RC	C1769	CPT				Both			189	85.05	85.05	170.1	154.26							Fee Schedule		139.86							Fee Schedule																													170.1							Fee Schedule																																															
ABBOTT VASCULAR GUIDEWIRE 2078173	272	RC	C1769	CPT				Both			409.5	184.28	154.26	368.55	154.26							Fee Schedule		303.03							Fee Schedule																													368.55							Fee Schedule																																															
ABBOTT VASCULAR PERCLOSE PROGLIDE 12673	272	RC	C1760	CPT				Both			787.5	354.38	114.86	708.75	114.86							Fee Schedule		582.75							Fee Schedule																													708.75							Fee Schedule																																															
ABBOTT VASCULAR STARCLOSE SE 14679-01	272	RC	C1760	CPT				Both			708.75	318.94	114.86	637.88	114.86							Fee Schedule		524.48							Fee Schedule																													637.88							Fee Schedule																																															
ABBOTT VASCULAR SUPERA STENT S-55-060-12	278	RC	C1876	CPT				Both			4252.5	1913.63	1913.63	3827.25		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	3146.85							Fee Schedule																													3827.25							Fee Schedule																																															
ABBOTT VASCULAR SUPERA STENT S-55-080-96	278	RC	C1876	CPT				Both			4252.5	1913.63	1913.63	3827.25		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	3146.85							Fee Schedule																													3827.25							Fee Schedule																																															
ABBOTT VASCULAR SUPERA STENT S-55-100-12	278	RC	C1876	CPT				Both			4252.5	1913.63	1913.63	3827.25		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	3146.85							Fee Schedule																													3827.25							Fee Schedule																																															
ABBOTT VASCULAR SUPERA STENT S-55-150-12	278	RC	C1876	CPT				Both			4252.5	1913.63	1913.63	3827.25		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	3146.85							Fee Schedule																													3827.25							Fee Schedule																																															
ABBOTT VASCULAR SUPERA STENT S-60-150-P6	278	RC	C1876	CPT				Both			4254	1914.3	1914.3	3828.6		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	3147.96							Fee Schedule																													3828.6							Fee Schedule																																															
ABBOTT VASCULAR SUPERA STENT S-65-080-12	278	RC	C1876	CPT				Both			4252.5	1913.63	1913.63	3827.25		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	3146.85							Fee Schedule																													3827.25							Fee Schedule																																															
ABBOTT VASCULAR SUPERA STENT S-65-100-12	278	RC	C1876	CPT				Both			4252.5	1913.63	1913.63	3827.25		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	3146.85							Fee Schedule																													3827.25							Fee Schedule																																															
ABBOTT VASCULAR SUPERA STENT S-65-100-12	278	RC	C1876	CPT				Both			4252.5	1913.63	1913.63	3827.25		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	3146.85							Fee Schedule																													3827.25							Fee Schedule																																															
ABBOTT VASCULAR SUPERA STENT S-65-120-12	278	RC	C1876	CPT				Both			4252.5	1913.63	1913.63	3827.25		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	3146.85							Fee Schedule																													3827.25							Fee Schedule																																															
ABBOTT VASCULAR SUPERA STENT S-65-150-12	278	RC	C1876	CPT				Both			4252.5	1913.63	1913.63	3827.25		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	3146.85							Fee Schedule																													3827.25							Fee Schedule																																															
ABBOTT VIATRAC CATHETER 1008189-20	272	RC	C1725	CPT				Both			390	175.5	93.3	351	93.3							Fee Schedule		288.6							Fee Schedule																													351							Fee Schedule																																															
ABBOTT VIATRAC CATHETER 1008190-15	272	RC	C1725	CPT				Both			409.5	184.28	93.3	368.55	93.3							Fee Schedule		303.03							Fee Schedule																													368.55							Fee Schedule																																															
ABBOTT VIATRAC CATHETER 1008190-20	272	RC	C1725	CPT				Both			409.5	184.28	93.3	368.55	93.3							Fee Schedule		303.03							Fee Schedule																													368.55							Fee Schedule																																															
ABBOTT VIATRAC CATHETER 1008192-15	272	RC	C1725	CPT				Both			409.5	184.28	93.3	368.55	93.3							Fee Schedule		303.03							Fee Schedule																													368.55							Fee Schedule																																															
ABBOTT VIATRAC CATHETER 1008192-20	272	RC	C1725	CPT				Both			409.5	184.28	93.3	368.55	93.3							Fee Schedule		303.03							Fee Schedule																													368.55							Fee Schedule																																															
ABBOTT VIATRAC CATHETER 1008194-15	272	RC	C1725	CPT				Both			409.5	184.28	93.3	368.55	93.3							Fee Schedule		303.03							Fee Schedule																													368.55							Fee Schedule																																															
ABBOTT VIATRAC CATHETER 1008196-15	272	RC	C1725	CPT				Both			409.5	184.28	93.3	368.55	93.3							Fee Schedule		303.03							Fee Schedule																													368.55							Fee Schedule																																															
ABBOTT VIATRAC CATHETER 1008198-15	272	RC	C1725	CPT				Both			409.5	184.28	93.3	368.55	93.3							Fee Schedule		303.03							Fee Schedule																													368.55							Fee Schedule																																															
ABD BINDER	271	RC						Both			57.23	25.75	25.75	51.51	37.2							Fee Schedule		42.35							Fee Schedule																													51.51							Fee Schedule																																															
ABD-EACH	272	RC						Both			1.05	0.47	0.47	0.95	0.68							Fee Schedule		0.78							Fee Schedule																													0.95							Fee Schedule																																															
ABDOMEN 1 VIEW	320	RC	74018	CPT				Both			315	141.75	13.33	318	14.73							Fee Schedule		17.4							Fee Schedule											13.33							Fee Schedule											283.5							Fee Schedule																				318							Per Diem																				
ABDOMEN 2 VIEWS	320	RC	74019	CPT				Both			315	141.75	15.96	318	17.64							Fee Schedule		20.97							Fee Schedule											15.96							Fee Schedule											283.5							Fee Schedule																				318							Per Diem																				
ABDOMEN 3 OR MORE VIEWS	320	RC	74021	CPT				Both			315	141.75	18.59	318	20.55							Fee Schedule		23.89							Fee Schedule											18.59							Fee Schedule											283.5							Fee Schedule																				318							Per Diem																				
ABDOMEN ACUTE SERIES	320	RC	74022	CPT				Both			315	141.75	20.94	318	23.17							Fee Schedule		27.47							Fee Schedule											20.94							Fee Schedule											283.5							Fee Schedule																				318							Per Diem																				
ABDOMEN KUB	320	RC	74018	CPT				Both			315	141.75	13.33	318	14.73							Fee Schedule		17.4							Fee Schedule											13.33							Fee Schedule											283.5							Fee Schedule																				318							Per Diem																				
ABDOMINAL BINDER 2XL 63''-74  #13663008	274	RC	L0625	CPT				Both			28	12.6	12.6	49.22		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	20.72							Fee Schedule		44.08							Fee Schedule											42.8							Fee Schedule		25.2							Fee Schedule		49.22							Fee Schedule		39.8							Fee Schedule											49.22							Fee Schedule		39.8							Fee Schedule		
ABDOMINAL BINDER 9   45-62  WIDTH	274	RC						Both			14.7	6.62	6.62	13.23		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	10.88							Fee Schedule																													13.23							Fee Schedule																																															
ABDOMINAL BINDER M/L 45-62  #79-89091	270	RC						Both			20	9	9	18	13							Fee Schedule		14.8							Fee Schedule																													18							Fee Schedule																																															
ABDOMINAL BINDER S/M 30-45  #79-89090	274	RC						Both			19	8.55	8.55	17.1		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	14.06							Fee Schedule																													17.1							Fee Schedule																																															
ABDOMINAL BINDER XL 42-48  #79-89048	270	RC						Both			31	13.95	13.95	27.9	20.15							Fee Schedule		22.94							Fee Schedule																													27.9							Fee Schedule																																															
ABDOMINAL STRAPS (SENECA) #40000008	274	RC	L0625	CPT				Both			3.15	1.42	1.42	49.22		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	2.33							Fee Schedule		44.08							Fee Schedule											42.8							Fee Schedule		2.84							Fee Schedule		49.22							Fee Schedule		39.8							Fee Schedule											49.22							Fee Schedule		39.8							Fee Schedule		
ABDOMINAL SUCTION POOLE(CONMED) 0035050	272	RC						Both			11	4.95	4.95	9.9	7.15							Fee Schedule		8.14							Fee Schedule																													9.9							Fee Schedule																																															
ABDS 8X7  #NON21453	272	RC	A6253	CPT				Both			1	0.45	0.45	10.38	5.7							Fee Schedule		0.74							Fee Schedule		9.3							Fee Schedule		7.13							Fee Schedule		9.03							Fee Schedule		0.9							Fee Schedule		10.38							Fee Schedule		8.4							Fee Schedule											10.38							Fee Schedule		8.4							Fee Schedule		
ABDUCTION PILLOW 79-90175	271	RC	E0190	CPT				Both			73	32.85	32.85	65.7	35.61							Fee Schedule		54.02							Fee Schedule																													65.7							Fee Schedule																																															
ABILIFY MAINTENA  400MG SYRINGE	636	RC	J0401	CPT				Both			10455.99	4705.2	6.77	9410.39		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	7.27							Fee Schedule		7.49							Fee Schedule											7.28							Fee Schedule		9410.39							Fee Schedule		8.37							Fee Schedule		6.77							Fee Schedule											8.37							Fee Schedule		6.77							Fee Schedule		
ABILIFY MAINTENA  400MG VIAL	636	RC	J0401	CPT				Both			10151.43	4568.14	6.77	9136.29		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	7.27							Fee Schedule		7.49							Fee Schedule											7.28							Fee Schedule		9136.29							Fee Schedule		8.37							Fee Schedule		6.77							Fee Schedule											8.37							Fee Schedule		6.77							Fee Schedule		
ABRADER 5.5 7205661  SMITH NEPHEW	272	RC						Both			202.65	91.19	91.19	182.39	131.72							Fee Schedule		149.96							Fee Schedule																													182.39							Fee Schedule																																															
ABRADOR BURR 2.9MM #72201518	272	RC						Both			155	69.75	69.75	139.5	100.75							Fee Schedule		114.7							Fee Schedule																													139.5							Fee Schedule																																															
ABRADOR BURR 3.5MM #72201519	272	RC						Both			162.75	73.24	73.24	146.48	105.79							Fee Schedule		120.44							Fee Schedule																													146.48							Fee Schedule																																															
ABRYSVO 120MCG/0.5ML INJECTION	636	RC	90678	CPT				Both			579.78	260.9	260.9	521.8		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	429.04							Fee Schedule																													521.8							Fee Schedule																																															
ABSORBABLE SUTURE CLIPS XC200	272	RC						Both			304	136.8	136.8	273.6	197.6							Fee Schedule		224.96							Fee Schedule																													273.6							Fee Schedule																																															
ABSORBER DISP MX50004  (DRAGER)	270	RC						Both			52	23.4	23.4	46.8	33.8							Fee Schedule		38.48							Fee Schedule																													46.8							Fee Schedule																																															
ABSORB-O-MAT 0702140038 STRYKER	271	RC						Both			23.1	10.4	10.4	20.79	15.02							Fee Schedule		17.09							Fee Schedule																													20.79							Fee Schedule																																															
ACARBOSE 50MG TABLET (PRECOSE)	250	RC	A9270	CPT				Both			5.25	2.36	0.01	4.73	0.01							Fee Schedule		3.89							Fee Schedule																													4.73							Fee Schedule																																															
ACCESSORY KIT AMS700 WITH PUMP #72401850	272	RC						Both			3555	1599.75	1599.75	3199.5	2310.75							Fee Schedule		2630.7							Fee Schedule																													3199.5							Fee Schedule																																															
ACCESSORY KIT AMS800 SPHINCTER 720066-01	272	RC						Both			4935	2220.75	2220.75	4441.5	3207.75							Fee Schedule		3651.9							Fee Schedule																													4441.5							Fee Schedule																																															
ACCLARENT BALLOON INFLATION DEV BID30	272	RC						Both			375	168.75	168.75	337.5	243.75							Fee Schedule		277.5							Fee Schedule																													337.5							Fee Schedule																																															
ACCLARENT INSPIRA AIR BALL. BC1640AZ	272	RC	C1726	CPT				Both			2820	1269	135.94	2538	135.94							Fee Schedule		2086.8							Fee Schedule																													2538							Fee Schedule																																															
ACCLARENT SINUPLASTY SYSTEM 6MMX16MM	272	RC						Both			6142.5	2764.13	2764.13	5528.25	3992.63							Fee Schedule		4545.45							Fee Schedule																													5528.25							Fee Schedule																																															
ACCU CATH  20 X 2.25  AC0202250	272	RC	C1751	CPT				Both			149	67.05	67.05	134.1	69.11							Fee Schedule		110.26							Fee Schedule																													134.1							Fee Schedule																																															
ACCU CATH 18X1.25 AC0181250  ACCESS	272	RC	C1751	CPT				Both			78	35.1	35.1	70.2	69.11							Fee Schedule		57.72							Fee Schedule																													70.2							Fee Schedule																																															
ACCU CATH 18X2.25 AC0182250  ACCESS	272	RC	C1751	CPT				Both			149	67.05	67.05	134.1	69.11							Fee Schedule		110.26							Fee Schedule																													134.1							Fee Schedule																																															
ACCU CATH 20 X 1.25  AC0201250	272	RC	C1751	CPT				Both			78	35.1	35.1	70.2	69.11							Fee Schedule		57.72							Fee Schedule																													70.2							Fee Schedule																																															
ACCU TYPE IL28B 90251 5ML EDTA TUBE	300	RC	81400	CPT				Both			1459.5	656.78	46.05	1313.55	46.05							Fee Schedule		63.96							Fee Schedule		65.88							Fee Schedule		63.96							Fee Schedule		63.96							Fee Schedule		1313.55							Fee Schedule		73.55							Fee Schedule		59.48							Fee Schedule		63.96							Fee Schedule		73.55							Fee Schedule		59.48							Fee Schedule		
ACCUFLEX MUNISCAL NEEDLES	272	RC						Both			56.7	25.52	25.52	51.03	36.86							Fee Schedule		41.96							Fee Schedule																													51.03							Fee Schedule																																															
ACCUPAP EZ PAP DEVICE W/ GAUGE 301-6001	271	RC						Both			71	31.95	31.95	63.9	46.15							Fee Schedule		52.54							Fee Schedule																													63.9							Fee Schedule																																															
ACCUSNARE	272	RC						Both			91.35	41.11	41.11	82.22	59.38							Fee Schedule		67.6							Fee Schedule																													82.22							Fee Schedule																																															
ACCUTYPE CLOPIDOGREL 16924 4ML LAV TOP	300	RC	81225	CPT				Both			472.5	212.63	209.78	425.25	209.78							Fee Schedule		291.36							Fee Schedule		300.1							Fee Schedule		291.36							Fee Schedule		291.36							Fee Schedule		425.25							Fee Schedule		335.06							Fee Schedule		270.96							Fee Schedule		291.36							Fee Schedule		335.06							Fee Schedule		270.96							Fee Schedule		
ACE 2  ELASTIC BANDAGE CONCOR	270	RC	A6448	CPT				Both			1	0.45	0.45	1.89	1.04							Fee Schedule		0.74							Fee Schedule		1.69							Fee Schedule		1.01							Fee Schedule		1.64							Fee Schedule		0.9							Fee Schedule		1.89							Fee Schedule		1.53							Fee Schedule											1.89							Fee Schedule		1.53							Fee Schedule		
ACE 3  ELASTIC BANDAGE	270	RC	A6449	CPT				Both			2	0.9	0.9	2.88	1.58							Fee Schedule		1.48							Fee Schedule		2.58							Fee Schedule		1.53							Fee Schedule		2.5							Fee Schedule		1.8							Fee Schedule		2.88							Fee Schedule		2.33							Fee Schedule											2.88							Fee Schedule		2.33							Fee Schedule		
ACE 4  ELASTIC BANDAGE #33400000	270	RC	A6449	CPT				Both			2	0.9	0.9	2.88	1.58							Fee Schedule		1.48							Fee Schedule		2.58							Fee Schedule		1.53							Fee Schedule		2.5							Fee Schedule		1.8							Fee Schedule		2.88							Fee Schedule		2.33							Fee Schedule											2.88							Fee Schedule		2.33							Fee Schedule		
ACE 6  ELASTIC BANDAGE #HCS5032-65LF	270	RC	A6450	CPT				Both			3	1.35	1.35	2.88	1.58							Fee Schedule		2.22							Fee Schedule		2.58							Fee Schedule											2.5							Fee Schedule		2.7							Fee Schedule		2.88							Fee Schedule		2.33							Fee Schedule											2.88							Fee Schedule		2.33							Fee Schedule		
ACE BANDAGE 4	271	RC						Both			6.3	2.84	2.84	5.67	4.1							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
ACE SUREFLEX W/VELCRO 2 INCH 59520000	270	RC	A6448	CPT				Both			2	0.9	0.9	1.89	1.04							Fee Schedule		1.48							Fee Schedule		1.69							Fee Schedule		1.01							Fee Schedule		1.64							Fee Schedule		1.8							Fee Schedule		1.89							Fee Schedule		1.53							Fee Schedule											1.89							Fee Schedule		1.53							Fee Schedule		
ACE SUREFLEX W/VELCRO 3 INCH 59530000	270	RC	A6449	CPT				Both			2	0.9	0.9	2.88	1.58							Fee Schedule		1.48							Fee Schedule		2.58							Fee Schedule		1.53							Fee Schedule		2.5							Fee Schedule		1.8							Fee Schedule		2.88							Fee Schedule		2.33							Fee Schedule											2.88							Fee Schedule		2.33							Fee Schedule		
ACE SUREFLEX W/VELCRO 4 INCH 59540000	270	RC	A6449	CPT				Both			2	0.9	0.9	2.88	1.58							Fee Schedule		1.48							Fee Schedule		2.58							Fee Schedule		1.53							Fee Schedule		2.5							Fee Schedule		1.8							Fee Schedule		2.88							Fee Schedule		2.33							Fee Schedule											2.88							Fee Schedule		2.33							Fee Schedule		
ACE SUREFLEX W/VELCRO 6 INCH MDS087006LF	270	RC	A6450	CPT				Both			3	1.35	1.35	2.88	1.58							Fee Schedule		2.22							Fee Schedule		2.58							Fee Schedule											2.5							Fee Schedule		2.7							Fee Schedule		2.88							Fee Schedule		2.33							Fee Schedule											2.88							Fee Schedule		2.33							Fee Schedule		
ACEBUTOLOL 200 MG CAPSULE UD	250	RC	A9270	CPT				Both			5.25	2.36	0.01	4.73	0.01							Fee Schedule		3.89							Fee Schedule																													4.73							Fee Schedule																																															
ACETABULAR CUP ALL POLY	278	RC	C1776	CPT				Both			1331.4	599.13	599.13	1198.26		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	985.24							Fee Schedule																													1198.26							Fee Schedule																																															
ACETAMINOPHEN	300	RC	80307	CPT				Both			100.8	45.36	45.36	90.72	51.72							Fee Schedule		64.65							Fee Schedule		64							Fee Schedule		62.14							Fee Schedule		62.14							Fee Schedule		90.72							Fee Schedule		71.46							Fee Schedule		57.79							Fee Schedule		62.14							Fee Schedule		71.46							Fee Schedule		57.79							Fee Schedule		
ACETAMINOPHEN 1000MG/100ML PREMIX	636	RC	J0136	CPT				Both			76	34.2	0.04	68.4		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	56.24							Fee Schedule		0.05							Fee Schedule											0.05							Fee Schedule		68.4							Fee Schedule		0.05							Fee Schedule		0.04							Fee Schedule											0.05							Fee Schedule		0.04							Fee Schedule		
ACETAMINOPHEN 120 MG SUPP	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
ACETAMINOPHEN 160 MG/5ML SOLUTION UD	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
ACETAMINOPHEN 160MG/5ML SUSPENSION 118ML	250	RC	A9270	CPT				Both			6	2.7	0.01	5.4	0.01							Fee Schedule		4.44							Fee Schedule																													5.4							Fee Schedule																																															
ACETAMINOPHEN 160MG/5ML SUSPENSION 473ML	250	RC	A9270	CPT				Both			9.45	4.25	0.01	8.51	0.01							Fee Schedule		6.99							Fee Schedule																													8.51							Fee Schedule																																															
ACETAMINOPHEN 325 MG TABLET	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
ACETAMINOPHEN 325 MG/10.15ML SOLUTION UD	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
ACETAMINOPHEN 325MG SUPPOSITORY (TYLENOL	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
ACETAMINOPHEN 500 MG (TYLENOL) TABLET	250	RC	A9270	CPT				Both			6	2.7	0.01	5.4	0.01							Fee Schedule		4.44							Fee Schedule																													5.4							Fee Schedule																																															
ACETAMINOPHEN 650MG SUPPOSITORY (TYLENOL	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
ACETAMINOPHEN 650MG/20.3ML SOL UD (TYLEN	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
ACETAMINOPHEN 80 MG/0.8ML INFT DROP-15ML	250	RC	A9270	CPT				Both			12.19	5.49	0.01	10.97	0.01							Fee Schedule		9.02							Fee Schedule																													10.97							Fee Schedule																																															
AcetaZOLAMIDE 250 MG TABLET UD	250	RC	A9270	CPT				Both			5.25	2.36	0.01	4.73	0.01							Fee Schedule		3.89							Fee Schedule																													4.73							Fee Schedule																																															
ACETAZOLAMIDE 500 MG/5ML INJECTION	636	RC	J1120	CPT				Both			123.9	55.76	26.16	111.51		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	91.69							Fee Schedule		28.97							Fee Schedule		40.1							Fee Schedule		28.13							Fee Schedule		111.51							Fee Schedule		32.35							Fee Schedule		26.16							Fee Schedule											32.35							Fee Schedule		26.16							Fee Schedule		
ACETIC ACID 5% 473ML BOTTLE	250	RC						Both			6	2.7	2.7	5.4	3.9							Fee Schedule		4.44							Fee Schedule																													5.4							Fee Schedule																																															
ACETIC ACID 5% 50ML- SINGLE USE	250	RC						Both			17.4	7.83	7.83	15.66	11.31							Fee Schedule		12.88							Fee Schedule																													15.66							Fee Schedule																																															
ACETONE BLOOD 205 GRAY TUBE	301	RC	82010	CPT				Both			74.55	33.55	7.26	67.1	7.26							Fee Schedule		9.08							Fee Schedule		8.42							Fee Schedule		8.17							Fee Schedule		8.17							Fee Schedule		67.1							Fee Schedule		9.4							Fee Schedule		7.6							Fee Schedule		8.17							Fee Schedule		9.4							Fee Schedule		7.6							Fee Schedule		
"ACETYL FENTANYL, QUAL, SER/PLASMA 91831"	301	RC	80354	CPT				Both			100.2	45.09	0.01	90.18	0.01							Fee Schedule									Other	No Additional Reimbursement 																												90.18							Fee Schedule																																															
"ACETYL FENTANYL, QUALITATIVE, URINE 9182"	301	RC	80354	CPT				Both			100.2	45.09	0.01	90.18	0.01							Fee Schedule									Other	No Additional Reimbursement 																												90.18							Fee Schedule																																															
ACETYLCHOLINE REC BLOCKING AB 34459	301	RC	86042	CPT				Both			248.85	111.98	17.11	223.97	161.75							Fee Schedule		18.4							Fee Schedule		18.95							Fee Schedule		18.4							Fee Schedule		18.4							Fee Schedule		223.97							Fee Schedule		21.16							Fee Schedule		17.11							Fee Schedule											21.16							Fee Schedule		17.11							Fee Schedule		
ACETYLCHOLINE REC MODULATION AB 26474	301	RC	86043	CPT				Both			156.45	70.4	11.21	140.81	101.69							Fee Schedule		12.05							Fee Schedule		12.41							Fee Schedule		12.05							Fee Schedule		12.05							Fee Schedule		140.81							Fee Schedule		13.86							Fee Schedule		11.21							Fee Schedule											13.86							Fee Schedule		11.21							Fee Schedule		
ACETYLCHOLINE RECEPTOR BINDING 206	301	RC	86041	CPT				Both			199.5	89.78	17.11	179.55	129.68							Fee Schedule		18.4							Fee Schedule		18.95							Fee Schedule		18.4							Fee Schedule		18.4							Fee Schedule		179.55							Fee Schedule		21.16							Fee Schedule		17.11							Fee Schedule											21.16							Fee Schedule		17.11							Fee Schedule		
ACETYLCYST 200MG/ML (20%)-30ML VIAL(PO)	250	RC						Both			78.75	35.44	35.44	70.88	51.19							Fee Schedule		58.28							Fee Schedule																													70.88							Fee Schedule																																															
ACETYLCYSTEINE 200MG/ML(20%) FOR IV ONLY	250	RC	J0132	CPT				Both			23	10.35	0.36	20.7	0.91							Fee Schedule		17.02							Fee Schedule		0.4							Fee Schedule											0.39							Fee Schedule		20.7							Fee Schedule		0.45							Fee Schedule		0.36							Fee Schedule											0.45							Fee Schedule		0.36							Fee Schedule		
ACETYLCYSTEINE DRIP	250	RC	J0132	CPT				Both			5	2.25	0.36	4.5	0.91							Fee Schedule		3.7							Fee Schedule		0.4							Fee Schedule											0.39							Fee Schedule		4.5							Fee Schedule		0.45							Fee Schedule		0.36							Fee Schedule											0.45							Fee Schedule		0.36							Fee Schedule		
ACHIEVE BIOPSY NEEDLE 14GX11CM CA1411	272	RC						Both			148	66.6	66.6	133.2	96.2							Fee Schedule		109.52							Fee Schedule																													133.2							Fee Schedule																																															
ACHIEVE BIOPSY NEEDLE 14GX9CM A149	272	RC						Both			115	51.75	51.75	103.5	74.75							Fee Schedule		85.1							Fee Schedule																													103.5							Fee Schedule																																															
ACID PHOS PROS 208 SERUM	301	RC	84066	CPT				Both			52.5	23.63	8.59	47.25	8.59							Fee Schedule		10.73							Fee Schedule		9.95							Fee Schedule		9.66							Fee Schedule		9.66							Fee Schedule		47.25							Fee Schedule		11.11							Fee Schedule		8.98							Fee Schedule		9.66							Fee Schedule		11.11							Fee Schedule		8.98							Fee Schedule		
ACID PHOS SERUM 210	301	RC	84060	CPT				Both			44.1	19.85	6.57	39.69	6.57							Fee Schedule		8.21							Fee Schedule		7.87							Fee Schedule		7.64							Fee Schedule		7.64							Fee Schedule		39.69							Fee Schedule		8.79							Fee Schedule		7.11							Fee Schedule		7.64							Fee Schedule		8.79							Fee Schedule		7.11							Fee Schedule		
ACL GUIDE WIRE	272	RC	C1769	CPT				Both			803.25	361.46	154.26	722.93	154.26							Fee Schedule		594.41							Fee Schedule																													722.93							Fee Schedule																																															
ACL GUIDE WIRE KIT	272	RC	C1769	CPT				Both			826.35	371.86	154.26	743.72	154.26							Fee Schedule		611.5							Fee Schedule																													743.72							Fee Schedule																																															
ACMI EZ GLIDER GUIDEWIRE #41BX	272	RC						Both			169.05	76.07	76.07	152.15	109.88							Fee Schedule		125.1							Fee Schedule																													152.15							Fee Schedule																																															
ACMI GUIDEWIRE 41BX	272	RC	C1769	CPT				Both			197.4	88.83	88.83	177.66	154.26							Fee Schedule		146.08							Fee Schedule																													177.66							Fee Schedule																																															
ACMI QUADRACOIL STENT 4.5 #5001945	278	RC	C1876	CPT				Both			460	207	207	414		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	340.4							Fee Schedule																													414							Fee Schedule																																															
ACMI QUADRACOIL STENT 6.0 #5001960	278	RC	C1876	CPT				Both			460	207	207	414		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	340.4							Fee Schedule																													414							Fee Schedule																																															
ACROBAT TIP WIRE GUIDE G32759 ( COOK )	272	RC	C1769	CPT				Both			598.5	269.33	154.26	538.65	154.26							Fee Schedule		442.89							Fee Schedule																													538.65							Fee Schedule																																															
ACROBAT TIP WIRE GUIDE G34266 ( COOK )	272	RC	C1769	CPT				Both			598.5	269.33	154.26	538.65	154.26							Fee Schedule		442.89							Fee Schedule																													538.65							Fee Schedule																																															
ACROBAT TIP WIRE GUIDE G34266 ( COOK )	272	RC	C1769	CPT				Both			598.5	269.33	154.26	538.65	154.26							Fee Schedule		442.89							Fee Schedule																													538.65							Fee Schedule																																															
ACROMINIZER BLADE 3452 (SMITHNEPHEWENDOS	272	RC						Both			202.65	91.19	91.19	182.39	131.72							Fee Schedule		149.96							Fee Schedule																													182.39							Fee Schedule																																															
ACROMIONIZER 5.5  7205663   SMITHNEPHEW	272	RC						Both			202.65	91.19	91.19	182.39	131.72							Fee Schedule		149.96							Fee Schedule																													182.39							Fee Schedule																																															
ACTH 80 UNITS/ML INJECTION-0.5ML VIAL	636	RC	J0800	CPT				Both			29.07	13.08	13.08	26.16		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	21.51							Fee Schedule																													26.16							Fee Schedule																																															
ACTH P LEVEL 211	301	RC	82024	CPT				Both			190.05	85.52	34.33	171.05	34.33							Fee Schedule		42.91							Fee Schedule		39.78							Fee Schedule		38.62							Fee Schedule		38.62							Fee Schedule		171.05							Fee Schedule		44.41							Fee Schedule		35.92							Fee Schedule		38.62							Fee Schedule		44.41							Fee Schedule		35.92							Fee Schedule		
ACTHAR INJ 25 UNITS	636	RC	J0800	CPT				Both			61.11	27.5	27.5	55		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	45.22							Fee Schedule																													55							Fee Schedule																																															
ACTHIB VACCINE	636	RC	90648	CPT				Both			37.8	17.01	17.01	34.02		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	27.97							Fee Schedule																													34.02							Fee Schedule																																															
ACTICOAT DRESSING 4X4 66800406	272	RC	A6207	CPT				Both			26	11.7	6.61	23.4	6.61							Fee Schedule		19.24							Fee Schedule		10.78							Fee Schedule		8.26							Fee Schedule		10.47							Fee Schedule		23.4							Fee Schedule		12.04							Fee Schedule		9.74							Fee Schedule											12.04							Fee Schedule		9.74							Fee Schedule		
ACTIFLO DRAINABLE COLLECTION 31003	272	RC						Both			44.1	19.85	19.85	39.69	28.67							Fee Schedule		32.63							Fee Schedule																													39.69							Fee Schedule																																															
ACTIFLO DRAINABLE KIT 32005	270	RC						Both			929.25	418.16	418.16	836.33	604.01							Fee Schedule		687.65							Fee Schedule																													836.33							Fee Schedule																																															
ACTION SPORTS BRACE LONG M 79-94305	274	RC						Both			149.1	67.1	67.1	134.19		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	110.33							Fee Schedule																													134.19							Fee Schedule																																															
ACTIVASE 100 MG INJECTION  (ALTEPLASE)	636	RC	J2997	CPT				Both			33264	14968.8	87.26	29937.6		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	95.09							Fee Schedule		96.65							Fee Schedule											93.83							Fee Schedule		29937.6							Fee Schedule		107.91							Fee Schedule		87.26							Fee Schedule											107.91							Fee Schedule		87.26							Fee Schedule		
ACTIVATED CHARCOAL/AQUA 25GM-120ML TUBE	250	RC	A9270	CPT				Both			52.5	23.63	0.01	47.25	0.01							Fee Schedule		38.85							Fee Schedule																													47.25							Fee Schedule																																															
ACTIVATED CHARCOAL/SORBITOL 25GM-120ML T	250	RC	A9270	CPT				Both			52.5	23.63	0.01	47.25	0.01							Fee Schedule		38.85							Fee Schedule																													47.25							Fee Schedule																																															
ACTONEL 5 MG TABLET UD	250	RC	A9270	CPT				Both			7.61	3.42	0.01	6.85	0.01							Fee Schedule		5.63							Fee Schedule																													6.85							Fee Schedule																																															
ACTOS 30 MG (PIOGLITAZONE) TABLET	250	RC	A9270	CPT				Both			33.6	15.12	0.01	30.24	0.01							Fee Schedule		24.86							Fee Schedule																													30.24							Fee Schedule																																															
ACTOS 45 MG (PIOGLITAZONE) TABLET	250	RC	A9270	CPT				Both			36.75	16.54	0.01	33.08	0.01							Fee Schedule		27.2							Fee Schedule																													33.08							Fee Schedule																																															
ACULAR 0.5% OPTH.SOL-3ML	250	RC	A9270	CPT				Both			173.5	78.08	0.01	156.15	0.01							Fee Schedule		128.39							Fee Schedule																													156.15							Fee Schedule																																															
ACUMED 3.5 CORT.SCREW 16MM #CO-3160	278	RC	C1713	CPT				Both			176.4	79.38	79.38	158.76		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	130.54							Fee Schedule																													158.76							Fee Schedule																																															
ACUMED 3.5 CORT.SCREW 25MM #CO-3250	278	RC	C1713	CPT				Both			176.4	79.38	79.38	158.76		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	130.54							Fee Schedule																													158.76							Fee Schedule																																															
ACUMED 3.5 CORT.SCREW 40MM #CO-3400	278	RC	C1713	CPT				Both			176.4	79.38	79.38	158.76		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	130.54							Fee Schedule																													158.76							Fee Schedule																																															
ACUMED 3.5 CORT.SCREW 8MM #CO-3080	278	RC	C1713	CPT				Both			176.4	79.38	79.38	158.76		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	130.54							Fee Schedule																													158.76							Fee Schedule																																															
ACUMED CORT. SCREW CO-F2710	278	RC	C1713	CPT				Both			113.4	51.03	51.03	102.06		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	83.92							Fee Schedule																													102.06							Fee Schedule																																															
ACUMED CORT. SCREW CO-F2716	278	RC	C1713	CPT				Both			113.4	51.03	51.03	102.06		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	83.92							Fee Schedule																													102.06							Fee Schedule																																															
ACUMED DRILL BIT MSDC 5020	272	RC						Both			96.6	43.47	43.47	86.94	62.79							Fee Schedule		71.48							Fee Schedule																													86.94							Fee Schedule																																															
ACUMED FIX SCREW 18.0 #ATM-180-S	278	RC	C1713	CPT				Both			1020.6	459.27	459.27	918.54		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	755.24							Fee Schedule																													918.54							Fee Schedule																																															
ACUMED FIX SCREW 20.0 #ATM-200-S	278	RC	C1713	CPT				Both			1020.6	459.27	459.27	918.54		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	755.24							Fee Schedule																													918.54							Fee Schedule																																															
ACUMED FIX SCREW 22.0 #ATM-220-S	278	RC	C1713	CPT				Both			1020.6	459.27	459.27	918.54		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	755.24							Fee Schedule																													918.54							Fee Schedule																																															
ACUMED GUIDE WIRE .35  #WS-0906	272	RC						Both			136.5	61.43	61.43	122.85	88.73							Fee Schedule		101.01							Fee Schedule																													122.85							Fee Schedule																																															
ACUMED PLATE POST PL-WF50	278	RC						Both			96.6	43.47	43.47	86.94		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	71.48							Fee Schedule																													86.94							Fee Schedule																																															
ACUMED SCREW COVER PL-WF60	278	RC						Both			283.5	127.58	127.58	255.15		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	209.79							Fee Schedule																													255.15							Fee Schedule																																															
NERVOUS SYSTEM NEOPLASMS WITH MCC					54	DRG		Inpatient			32432.41	14594.58	14594.58	14594.58							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period	
DEGENERATIVE NERVOUS SYSTEM DISORDERS WITHOUT MCC					57	DRG		Inpatient			14110.74	6349.83	6349.83	6349.83							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period	
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH MCC					64	DRG		Inpatient			50542.43	22744.09	22744.09	22744.09							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period							0		No services provided during 15 month lookback period				6409.26	6409.26	6409.26	1 through 10									0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period	
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH CC OR TP					65	DRG		Inpatient			30401.9	13680.85	13680.85	13680.85							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period				3968.06	3968.06	3968.06	1 through 10						1422.13	1422.13	1422.13	1 through 10						23986.79	23986.79	23986.79	1 through 10									0		No services provided during 15 month lookback period				4115.18	4115.18	4115.18	1 through 10									0		No services provided during 15 month lookback							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period	
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITHOUT CC/MC					66	DRG		Inpatient			23085.33	10388.4	10388.4	10388.4							0		No services performed during 15 month lookback period. 				4774.9	4774.9	4774.9	1 through 10									0		No services performed during 15 month lookback period							0		No services provided during 15 month lookback period				1422.13	1422.13	1422.13	1 through 10									0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback				610260	610260	610260	1 through 10		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period	
TRANSIENT ISCHEMIA WITHOUT THROMBOLYTIC					69	DRG		Inpatient			21703.99	9766.8	9766.8	9766.8							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period							0		No services provided during 15 month lookback period				4347.55	4347.55	4347.55	1 through 10									0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period	
OTHER CEREBROVASCULAR DISORDERS WITH CC					71	DRG		Inpatient			33750.46	15187.71	15187.71	15187.71							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period							0		No services provided during 15 month lookback period				6570.23	6570.23	6570.23	1 through 10									0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period	
OTHER CEREBROVASCULAR DISORDERS WITHOUT CC/MCC					72	DRG		Inpatient			23069.29	10381.18	10381.18	10381.18							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period							0		No services provided during 15 month lookback period				11902.94	11902.94	11902.94	1 through 10									0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period	
ACUTRAK BONE SCREW 40 MM	272	RC	C1713	CPT				Both			843.15	379.42	306.41	758.84	306.41							Fee Schedule		623.93							Fee Schedule																							6315.1	6315.1	6315.1				758.84							Fee Schedule																																					No services provided during 15 month lookback period										
ACUTRAK GUIDE WIRE	272	RC						Both			34.65	15.59	15.59	31.19	22.52							Fee Schedule		25.64							Fee Schedule																							5032.18	5032.18	5032.18				31.19							Fee Schedule																																					No services provided during 15 month lookback period										
ACUTRAK GUIDE WIRE WS-1106ST	272	RC						Both			34.65	15.59	15.59	31.19	22.52							Fee Schedule		25.64							Fee Schedule																							4961.75	4961.75	4961.75				31.19							Fee Schedule																																					No services provided during 15 month lookback period										
ACYCLOVIR  200 MG (ZOVIRAX) CAPSULE	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																							6769.85	6769.85	6769.85				5.67							Fee Schedule																																					No services provided during 15 month lookback period										
ACYCLOVIR  800 MG (ZOVIRAX) TABLET	250	RC	A9270	CPT				Both			14.7	6.62	0.01	13.23	0.01							Fee Schedule		10.88							Fee Schedule																							4397.79	4397.79	4397.79				13.23							Fee Schedule																																					No services provided during 15 month lookback period										
ACYCLOVIR (ZOVIRAX) 5%  OINT 15 GM	636	RC	A9270	CPT				Both			90	40.5	40.5	81		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	66.6							Fee Schedule																							5669.61	5669.61	5669.61				81							Fee Schedule																																					No services provided during 15 month lookback period										
ACYCLOVIR (ZOVIRAX) 5%  OINT 30 GM	636	RC	A9270	CPT				Both			90	40.5	40.5	81		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	66.6							Fee Schedule																							4736.45	4736.45	4736.45				81							Fee Schedule																																					No services provided during 15 month lookback period										
ACYCLOVIR (ZOVIRAX) CREAM 5GM	250	RC	A9270	CPT				Both			2021.25	909.56	0.01	1819.13	0.01							Fee Schedule		1495.73							Fee Schedule																							3750.11	3750.11	3750.11				1819.13							Fee Schedule																																					No services provided during 15 month lookback period										
ACYCLOVIR 1000 MG/250ML NS(ZOVIRAX) IVPB	250	RC	J0133	CPT				Both			144.9	65.21	0.03	130.41	0.05							Fee Schedule		107.23							Fee Schedule		0.04							Fee Schedule											0.04			5335.18	5335.18	5335.18		Fee Schedule		130.41							Fee Schedule		0.04							Fee Schedule		0.03							Fee Schedule											0.04							Fee Schedule	No services provided during 15 month lookback period	0.03							Fee Schedule		
ACYCLOVIR 1000MG/20ML VIAL	636	RC	J0133	CPT				Both			126	56.7	0.03	113.4		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	93.24							Fee Schedule		0.04							Fee Schedule											0.04			7198.85	7198.85	7198.85		Fee Schedule		113.4							Fee Schedule		0.04							Fee Schedule		0.03							Fee Schedule											0.04							Fee Schedule	No services provided during 15 month lookback period	0.03							Fee Schedule		
ACYCLOVIR 200 MG/5ML ORAL SUSP UD	250	RC	A9270	CPT				Both			5.25	2.36	0.01	4.73	0.01							Fee Schedule		3.89							Fee Schedule																							5478.08	5478.08	5478.08				4.73							Fee Schedule																																					No services provided during 15 month lookback period										
ACYCLOVIR 5% OINTMENT- 3GM	250	RC	A9270	CPT				Both			65.14	29.31	0.01	58.63	0.01							Fee Schedule		48.2							Fee Schedule																							39187.45	39187.45	39187.45				58.63							Fee Schedule																																					No services provided during 15 month lookback period										
ACYCLOVIR 500 MG/NS 100ML (ZOVIRAX) IVPB	636	RC	J0133	CPT				Both			78.75	35.44	0.03	70.88		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	58.28							Fee Schedule		0.04							Fee Schedule											0.04			9028.52	9028.52	9028.52		Fee Schedule		70.88							Fee Schedule		0.04							Fee Schedule		0.03							Fee Schedule											0.04							Fee Schedule	No services provided during 15 month lookback period	0.03							Fee Schedule		
ACYCLOVIR 500MG/10ML VIAL	636	RC	J0133	CPT				Both			48	21.6	0.03	43.2		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	35.52							Fee Schedule		0.04							Fee Schedule											0.04			7426.89	7426.89	7426.89		Fee Schedule		43.2							Fee Schedule		0.04							Fee Schedule		0.03							Fee Schedule											0.04							Fee Schedule	No services provided during 15 month lookback period	0.03							Fee Schedule		
ADACEL (Tdap) 0.5 ML VACCINE	636	RC	90715	CPT				Both			61.95	27.88	27.88	55.76		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	45.84							Fee Schedule		41.5							Fee Schedule											40.29			11459.96	11459.96	11459.96		Fee Schedule		55.76							Fee Schedule		46.33							Fee Schedule		37.47							Fee Schedule											46.33							Fee Schedule	No services provided during 15 month lookback period	37.47							Fee Schedule		
ADALIMUMAB DRUG LEVEL AND IBD AB 36296	301	RC	80145	CPT				Both			579	260.55	27.77	521.1	27.77							Fee Schedule		38.57							Fee Schedule		39.73							Fee Schedule		38.57							Fee Schedule		38.57			7314.99	7314.99	7314.99		Fee Schedule		521.1							Fee Schedule		44.36							Fee Schedule		35.87							Fee Schedule		38.57							Fee Schedule		44.36							Fee Schedule	No services provided during 15 month lookback period	35.87							Fee Schedule		
ADAMS TS13 14532 1ML PLASMA FROZEN	305	RC	85397	CPT				Both			262.5	118.13	22.22	236.25	22.22							Fee Schedule		30.86							Fee Schedule		31.79							Fee Schedule		30.86							Fee Schedule		30.86			5131.79	5131.79	5131.79		Fee Schedule		236.25							Fee Schedule		35.49							Fee Schedule		28.7							Fee Schedule		30.86							Fee Schedule		35.49							Fee Schedule	No services provided during 15 month lookback period	28.7							Fee Schedule		
ADAPT PASTE #79300	272	RC	A4406	CPT				Both			14	6.3	5.15	12.6	5.15							Fee Schedule		10.36							Fee Schedule		8.4							Fee Schedule											8.16			6463.69	6463.69	6463.69		Fee Schedule		12.6							Fee Schedule		9.38							Fee Schedule		7.59							Fee Schedule											9.38							Fee Schedule	No services provided during 15 month lookback period	7.59							Fee Schedule		
ADAPTER (PRN)	272	RC						Both			3.15	1.42	1.42	2.84	2.05							Fee Schedule		2.33							Fee Schedule																							4478.36	4478.36	4478.36				2.84							Fee Schedule																																					No services provided during 15 month lookback period										
ADAPTER CATH	272	RC						Both			2.1	0.95	0.95	1.89	1.37							Fee Schedule		1.55							Fee Schedule																							6851.28	6851.28	6851.28				1.89							Fee Schedule																																					No services provided during 15 month lookback period										
ADAPTIC 3X4 EACH	272	RC	A6223	CPT				Both			2.1	0.95	0.95	3.98	2.18							Fee Schedule		1.55							Fee Schedule		3.56							Fee Schedule		2.73							Fee Schedule		3.46			3389.79	3389.79	3389.79		Fee Schedule		1.89							Fee Schedule		3.98							Fee Schedule		3.22							Fee Schedule											3.98							Fee Schedule	No services provided during 15 month lookback period	3.22							Fee Schedule		
ADAPTIC 3X8 EACH	272	RC						Both			3.15	1.42	1.42	2.84	2.05							Fee Schedule		2.33							Fee Schedule																							3570.64	3570.64	3570.64				2.84							Fee Schedule																																					No services provided during 15 month lookback period										
ADAPTIC DRES 3X16	272	RC						Both			4.2	1.89	1.89	3.78	2.73							Fee Schedule		3.11							Fee Schedule																							4620.96	4620.96	4620.96				3.78							Fee Schedule																																					No services provided during 15 month lookback period										
ADAPTIC TOUCH DRESSING 2X3 #TCH501	272	RC	A6206	CPT				Both			5	2.25	2.25	4.5	2.34							Fee Schedule		3.7							Fee Schedule																							31798.27	31798.27	31798.27				4.5							Fee Schedule																																					No services provided during 15 month lookback period										
ADAPTOR HI HUMID. 28-98% #371-1018 (TRIA	272	RC						Both			13.65	6.14	6.14	12.29	8.87							Fee Schedule		10.1							Fee Schedule																							27440.06	27440.06	27440.06				12.29							Fee Schedule																																					No services provided during 15 month lookback period										
ADAPTOR MULTI #1422	270	RC						Both			1	0.45	0.45	0.9	0.65							Fee Schedule		0.74							Fee Schedule																							11711.17	11711.17	11711.17				0.9							Fee Schedule																																					No services provided during 15 month lookback period										
ADAPTOR NIF-TEE   33-3500	270	RC						Both			14.02	6.31	6.31	12.62	9.11							Fee Schedule		10.37							Fee Schedule																							8318.88	8318.88	8318.88				12.62							Fee Schedule																																					No services provided during 15 month lookback period										
ADAPTOR OXYGEN TUBING MALE TO MALE 1420	270	RC						Both			1	0.45	0.45	0.9	0.65							Fee Schedule		0.74							Fee Schedule																							9869.66	9869.66	9869.66				0.9							Fee Schedule																																					No services provided during 15 month lookback period										
ADDL SEQUENTIAL INFUSION OF NEW DRUG/SUB	260	RC	96367	CPT				Both			84	37.8	27.13	75.6	28.69							Fee Schedule		62.16							Fee Schedule											27.13							Fee Schedule					5424.73	5424.73	5424.73				75.6							Fee Schedule																																					No services provided during 15 month lookback period										
ADENOCARD  6 MG/2ML SYRINGE	636	RC	J0153	CPT				Both			60.9	27.41	0.37	54.81		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	45.07							Fee Schedule		0.41							Fee Schedule											0.39			2640.53	2640.53	2640.53		Fee Schedule		54.81							Fee Schedule		0.45							Fee Schedule		0.37							Fee Schedule											0.45							Fee Schedule	No services provided during 15 month lookback period	0.37							Fee Schedule		
ADENOCARD 12 MG/4ML INJ	636	RC	J0153	CPT				Both			98.7	44.42	0.37	88.83		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	73.04							Fee Schedule		0.41							Fee Schedule											0.39			4571.04	4571.04	4571.04		Fee Schedule		88.83							Fee Schedule		0.45							Fee Schedule		0.37							Fee Schedule											0.45							Fee Schedule	No services provided during 15 month lookback period	0.37							Fee Schedule		
ADENOSINE  6 MG/2ML VIAL	636	RC	J0153	CPT				Both			24.15	10.87	0.37	21.74		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	17.87							Fee Schedule		0.41							Fee Schedule											0.39			3425.67	3425.67	3425.67		Fee Schedule		21.74							Fee Schedule		0.45							Fee Schedule		0.37							Fee Schedule											0.45							Fee Schedule	No services provided during 15 month lookback period	0.37							Fee Schedule		
ADENOVIRUS AB 686 SERUM	302	RC	86603	CPT				Both			85.05	38.27	11.44	76.55	11.44							Fee Schedule		14.3							Fee Schedule		13.26							Fee Schedule		12.87							Fee Schedule		12.87			3157.59	3157.59	3157.59		Fee Schedule		76.55							Fee Schedule		14.8							Fee Schedule		11.97							Fee Schedule		12.87							Fee Schedule		14.8							Fee Schedule	No services provided during 15 month lookback period	11.97							Fee Schedule		
ADENOVIRUS DNA QUAL/PCR 16046	302	RC	87798	CPT				Both			189	85.05	31.2	170.1	31.2							Fee Schedule		38.99							Fee Schedule		36.14							Fee Schedule		35.09							Fee Schedule		35.09			5371.71	5371.71	5371.71		Fee Schedule		170.1							Fee Schedule		40.35							Fee Schedule		32.63							Fee Schedule		35.09							Fee Schedule		40.35							Fee Schedule	No services provided during 15 month lookback period	32.63							Fee Schedule		
ADIPONECTIN  QUEST 15060	302	RC	83520	CPT				Both			369	166.05	12.43	332.1	12.43							Fee Schedule		17.27							Fee Schedule		17.79							Fee Schedule		17.27							Fee Schedule		17.27			5176.9	5176.9	5176.9		Fee Schedule		332.1							Fee Schedule		19.86							Fee Schedule		16.06							Fee Schedule		17.27							Fee Schedule		19.86							Fee Schedule	No services provided during 15 month lookback period	16.06							Fee Schedule		
ADJUSTABLE HEAD PILLOW LHP100	271	RC						Both			43	19.35	19.35	38.7	27.95							Fee Schedule		31.82							Fee Schedule																													38.7							Fee Schedule																																					No services provided during 15 month lookback period										
ADJUSTABLE HEEL LIFT LG 928650	270	RC						Both			12	5.4	5.4	10.8	7.8							Fee Schedule		8.88							Fee Schedule																													10.8							Fee Schedule																																					No services provided during 15 month lookback period										
ADJUSTABLE HEEL LIFT MED 928649	270	RC						Both			12	5.4	5.4	10.8	7.8							Fee Schedule		8.88							Fee Schedule																													10.8							Fee Schedule																																					No services provided during 15 month lookback period										
ADJUSTABLE HEEL LIFT SM 928648	270	RC						Both			12	5.4	5.4	10.8	7.8							Fee Schedule		8.88							Fee Schedule																													10.8							Fee Schedule																																					No services provided during 15 month lookback period										
ADM  VACCINE FLU	771	RC	90471	CPT				Both			94.5	42.53	4.47	85.05	10							Fee Schedule		69.93							Fee Schedule											4.47							Fee Schedule											85.05							Fee Schedule																																					No services provided during 15 month lookback period										
ADM  VACCINE OTHER	771	RC	90471	CPT				Both			94.5	42.53	4.47	85.05	10							Fee Schedule		69.93							Fee Schedule											4.47							Fee Schedule											85.05							Fee Schedule																																					No services provided during 15 month lookback period										
ADMIN OF BEYFORTIS VACCINE	771	RC	96381	CPT				Both			77.85	35.03	15.48	70.07	50.6							Fee Schedule		57.61							Fee Schedule											15.48							Fee Schedule											70.07							Fee Schedule																																					No services provided during 15 month lookback period										
ADMIN OF INFLUENZA VACCINE	771	RC	G0008	CPT				Both			94.5	42.53	4.06	85.05	7.68							Fee Schedule		69.93							Fee Schedule		49.28							Fee Schedule		4.06							Fee Schedule		47.84							Fee Schedule		85.05							Fee Schedule		55.02							Fee Schedule		44.49							Fee Schedule											55.02							Fee Schedule	No services provided during 15 month lookback period	44.49							Fee Schedule		
ADMIN OF SPIKEVAX	771	RC	90480	CPT				Both			120.52	54.23	34.85	108.47	78.34							Fee Schedule		89.18							Fee Schedule											34.85							Fee Schedule											108.47							Fee Schedule																																					No services provided during 15 month lookback period										
ADMINISTRATION  VACCINE HEP B	771	RC	90471	CPT				Both			94.5	42.53	4.47	85.05	10							Fee Schedule		69.93							Fee Schedule											4.47							Fee Schedule											85.05							Fee Schedule																																					No services provided during 15 month lookback period										
ADMIX NONCOMPOUNDED LVP INFUSION THERAPY	250	RC						Both			84	37.8	37.8	75.6	54.6							Fee Schedule		62.16							Fee Schedule																													75.6							Fee Schedule																																					No services provided during 15 month lookback period										
ADRENAL AB WITH REFLX TO TITER 4645	302	RC	86255	CPT				Both			29.88	13.45	10.71	26.89	10.71							Fee Schedule		13.39							Fee Schedule		12.41							Fee Schedule		12.05							Fee Schedule		12.05							Fee Schedule		26.89							Fee Schedule		13.86							Fee Schedule		11.21							Fee Schedule		12.05							Fee Schedule		13.86							Fee Schedule	No services provided during 15 month lookback period	11.21							Fee Schedule		
ADRENALIN TOPICAL SOLN 1:1000-30ML	250	RC	A9270	CPT				Both			79.44	35.75	0.01	71.5	0.01							Fee Schedule		58.79							Fee Schedule																													71.5							Fee Schedule																																					No services provided during 15 month lookback period										
ADULT DIAPERS EACH	272	RC	A4335	CPT				Both			3.68	1.66	1.66	3.31	2.39							Fee Schedule		2.72							Fee Schedule																													3.31							Fee Schedule																																					No services provided during 15 month lookback period										
ADULT DIAPERS LG MEDLINE	271	RC	A4520	CPT				Both			21	9.45	1	18.9	1							Fee Schedule		15.54							Fee Schedule																													18.9							Fee Schedule																																					No services provided during 15 month lookback period										
ADULT DIAPERS MED 12PK. (SENECA)	271	RC	A4520	CPT				Both			9.45	4.25	1	8.51	1							Fee Schedule		6.99							Fee Schedule																													8.51							Fee Schedule																																					No services provided during 15 month lookback period										
ADULT DIAPERS MED WHITE	271	RC	A4520	CPT				Both			1	0.45	0.45	1	1							Fee Schedule		0.74							Fee Schedule																													0.9							Fee Schedule																																					No services provided during 15 month lookback period										
ADULT DIAPERS PULL UP'S LG.	271	RC	A4520	CPT				Both			1.65	0.74	0.74	1.49	1							Fee Schedule		1.22							Fee Schedule																													1.49							Fee Schedule																																					No services provided during 15 month lookback period										
ADULT DIAPERS SM 12PK (SENECA)	271	RC	A4520	CPT				Both			6	2.7	1	5.4	1							Fee Schedule		4.44							Fee Schedule																													5.4							Fee Schedule																																					No services provided during 15 month lookback period										
ADULT DIAPERS XLG	271	RC	A4520	CPT				Both			12.6	5.67	1	11.34	1							Fee Schedule		9.32							Fee Schedule																													11.34							Fee Schedule																																					No services provided during 15 month lookback period										
ADVAIR 100/50 MCG DISKUS-14	250	RC	A9270	CPT				Both			295.91	133.16	0.01	266.32	0.01							Fee Schedule		218.97							Fee Schedule																													266.32							Fee Schedule																																					No services provided during 15 month lookback period										
ADVAIR 250/50 MCG DISKUS-14	250	RC	A9270	CPT				Both			295.91	133.16	0.01	266.32	0.01							Fee Schedule		218.97							Fee Schedule																													266.32							Fee Schedule																																					No services provided during 15 month lookback period										
ADVAIR 500/50 MCG DISKUS-14	250	RC	A9270	CPT				Both			482.33	217.05	0.01	434.1	0.01							Fee Schedule		356.92							Fee Schedule																													434.1							Fee Schedule																																					No services provided during 15 month lookback period										
ADVANIX BILIARY STENT #M00533020	272	RC						Both			172	77.4	77.4	154.8	111.8							Fee Schedule		127.28							Fee Schedule																													154.8							Fee Schedule																																					No services provided during 15 month lookback period										
ADVANIX BILIARY STENT 10F 5CM #M00532990	278	RC	C1874	CPT				Both			172	77.4	77.4	154.8		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	127.28							Fee Schedule																													154.8							Fee Schedule																																					No services provided during 15 month lookback period										
ADVANIX BILIARY STENT 10F 7CM #M00534330	272	RC						Both			1254	564.3	564.3	1128.6	815.1							Fee Schedule		927.96							Fee Schedule																													1128.6							Fee Schedule																																					No services provided during 15 month lookback period										
ADVANIX BILIARY STENT 10F 9CM #M00534340	272	RC						Both			418	188.1	188.1	376.2	271.7							Fee Schedule		309.32							Fee Schedule																													376.2							Fee Schedule																																					No services provided during 15 month lookback period										
ADVANIX BILIARY STENT 10F15CM #M00534360	272	RC						Both			418	188.1	188.1	376.2	271.7							Fee Schedule		309.32							Fee Schedule																													376.2							Fee Schedule																																					No services provided during 15 month lookback period										
ADVANIX BILIARY STENT 10FX7CM M00534330	278	RC	C2625	CPT				Both			411.6	185.22	185.22	370.44		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	304.58							Fee Schedule																													370.44							Fee Schedule																																					No services provided during 15 month lookback period										
ADVANIX BILIARY STENT 7F 9CM #M00534220	278	RC	C1874	CPT				Both			418	188.1	188.1	376.2		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	309.32							Fee Schedule																													376.2							Fee Schedule																																					No services provided during 15 month lookback period										
ADVINCULA DELINEATOR 2.5CM AD750-KE25	272	RC						Both			975	438.75	438.75	877.5	633.75							Fee Schedule		721.5							Fee Schedule																													877.5							Fee Schedule																																					No services provided during 15 month lookback period										
ADVINCULA DELINEATOR 3.0CM AD750-KE30	272	RC						Both			975	438.75	438.75	877.5	633.75							Fee Schedule		721.5							Fee Schedule																													877.5							Fee Schedule																																					No services provided during 15 month lookback period										
ADVINCULA DELINEATOR 3.5CM AD750-KE35	272	RC						Both			975	438.75	438.75	877.5	633.75							Fee Schedule		721.5							Fee Schedule																													877.5							Fee Schedule																																					No services provided during 15 month lookback period										
ADVINCULA DELINEATOR 4.0CM AD750-KE40	272	RC						Both			975	438.75	438.75	877.5	633.75							Fee Schedule		721.5							Fee Schedule																													877.5							Fee Schedule																																					No services provided during 15 month lookback period										
AER 40 WITCH HAZEL PADS	250	RC	A9270	CPT				Both			8.4	3.78	0.01	7.56	0.01							Fee Schedule		6.22							Fee Schedule																													7.56							Fee Schedule																																					No services provided during 15 month lookback period										
AEROBID INHALER-7GM	250	RC	A9270	CPT				Both			296.19	133.29	0.01	266.57	0.01							Fee Schedule		219.18							Fee Schedule																													266.57							Fee Schedule																																					No services provided during 15 month lookback period										
AEROS INIT W/1.25 XOP/ATROVENT	412	RC	94640	CPT				Both			283.5	127.58	12.53	286	175							Per Diem		209.79							Fee Schedule											12.53							Fee Schedule											255.15							Fee Schedule																				286							Case Rate										No services provided during 15 month lookback period										
AEROS INIT W/ALUP/ NSS	412	RC	94664	CPT				Both			283.5	127.58	16.28	286	175							Per Diem		209.79							Fee Schedule											16.28							Fee Schedule											255.15							Fee Schedule																				286							Case Rate										No services provided during 15 month lookback period										
AEROS INIT W/LIDOCAINE	412	RC	94640	CPT				Both			283.5	127.58	12.53	286	175							Per Diem		209.79							Fee Schedule											12.53							Fee Schedule											255.15							Fee Schedule																				286							Case Rate										No services provided during 15 month lookback period										
AEROS INIT W/PROV & INTAL	412	RC	94640	CPT				Both			283.5	127.58	12.53	286	175							Per Diem		209.79							Fee Schedule											12.53							Fee Schedule											255.15							Fee Schedule																				286							Case Rate										No services provided during 15 month lookback period										
AEROS MASK (ADULT)	271	RC	A7003	CPT				Both			3	1.35	1.18	2.7	1.18							Fee Schedule		2.22							Fee Schedule		1.95							Fee Schedule											1.89							Fee Schedule		2.7							Fee Schedule		2.17							Fee Schedule		1.76							Fee Schedule											2.17							Fee Schedule	No services provided during 15 month lookback period	1.76							Fee Schedule		
AEROS MASK 1083 HUDSON (SENECA)	271	RC						Both			2.1	0.95	0.95	1.89	1.37							Fee Schedule		1.55							Fee Schedule																													1.89							Fee Schedule																																					No services provided during 15 month lookback period										
AEROSOL INITIAL 0.31 XOPENEX	412	RC	94640	CPT				Both			283.5	127.58	12.53	286	175							Per Diem		209.79							Fee Schedule											12.53							Fee Schedule											255.15							Fee Schedule																				286							Case Rate										No services provided during 15 month lookback period										
AEROSOL INITIAL DUONEB	412	RC	94640	CPT				Both			283.5	127.58	12.53	286	175							Per Diem		209.79							Fee Schedule											12.53							Fee Schedule											255.15							Fee Schedule																				286							Case Rate										No services provided during 15 month lookback period										
AEROSOL MASK ADULT 8100 (HUD1083)	271	RC						Both			2	0.9	0.9	1.8	1.3							Fee Schedule		1.48							Fee Schedule																													1.8							Fee Schedule																																					No services provided during 15 month lookback period										
AEROSOL NEBUTECH 8982 (TRI-ANIM)	271	RC						Both			19.43	8.74	8.74	17.49	12.63							Fee Schedule		14.38							Fee Schedule																													17.49							Fee Schedule																																					No services provided during 15 month lookback period										
AEROSOL PEDIATRIC PACIFIER 963-0382EA	271	RC	A7004	CPT				Both			24	10.8	0.99	21.6	0.99							Fee Schedule		17.76							Fee Schedule		1.64							Fee Schedule											1.59							Fee Schedule		21.6							Fee Schedule		1.83							Fee Schedule		1.48							Fee Schedule											1.83							Fee Schedule	No services provided during 15 month lookback period	1.48							Fee Schedule		
AEROSOL RX SUB	412	RC	94640	CPT				Both			283.5	127.58	12.53	286	175							Per Diem		209.79							Fee Schedule											12.53							Fee Schedule											255.15							Fee Schedule																				286							Case Rate										No services provided during 15 month lookback period										
AEROSOL W LIDOCAINE	412	RC	94640	CPT				Both			283.5	127.58	12.53	286	175							Per Diem		209.79							Fee Schedule											12.53							Fee Schedule											255.15							Fee Schedule																				286							Case Rate										No services provided during 15 month lookback period										
AESCULA ASPIRATION NEEDLE SR550R	272	RC						Both			1064	478.8	478.8	957.6	691.6							Fee Schedule		787.36							Fee Schedule																													957.6							Fee Schedule																																					No services provided during 15 month lookback period										
AFB STAIN SPUTUM	306	RC	87206	CPT				Both			111.3	50.09	4.79	100.17	4.79							Fee Schedule		5.99							Fee Schedule		5.55							Fee Schedule		5.39							Fee Schedule		5.39							Fee Schedule		100.17							Fee Schedule		6.2							Fee Schedule		5.01							Fee Schedule		5.39							Fee Schedule		6.2							Fee Schedule	No services provided during 15 month lookback period	5.01							Fee Schedule		
AFB STAIN SPUTUM TO REF LAB 4503	306	RC	87206	CPT				Both			106.05	47.72	4.79	95.45	4.79							Fee Schedule		5.99							Fee Schedule		5.55							Fee Schedule		5.39							Fee Schedule		5.39							Fee Schedule		95.45							Fee Schedule		6.2							Fee Schedule		5.01							Fee Schedule		5.39							Fee Schedule		6.2							Fee Schedule	No services provided during 15 month lookback period	5.01							Fee Schedule		
AFFINITY ALLOGRAFT 1.5CMX1.5CM #AF-1150	278	RC	Q4159	CPT				Both			1150	517.5	118.24	1035		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	851							Fee Schedule		130.95							Fee Schedule											127.14							Fee Schedule		1035							Fee Schedule		146.21							Fee Schedule		118.24							Fee Schedule											146.21							Fee Schedule	No services provided during 15 month lookback period	118.24							Fee Schedule		
AFFINITY ALLOGRAFT 2.5CMX2.5CM #AF-1250	278	RC	Q4159	CPT				Both			547	246.15	118.24	492.3		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	404.78							Fee Schedule		130.95							Fee Schedule											127.14							Fee Schedule		492.3							Fee Schedule		146.21							Fee Schedule		118.24							Fee Schedule											146.21							Fee Schedule	No services provided during 15 month lookback period	118.24							Fee Schedule		
AFO  DEMI BOOT DR.BOWMAN	274	RC	L1930	CPT				Both			135.45	60.95	60.95	312.62		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	100.23							Fee Schedule		280							Fee Schedule		213.89							Fee Schedule		271.84							Fee Schedule		121.91							Fee Schedule		312.62							Fee Schedule		252.81							Fee Schedule											312.62							Fee Schedule	No services provided during 15 month lookback period	252.81							Fee Schedule		
AFO CLEFT	274	RC	L1906	CPT				Both			236.25	106.31	106.31	212.63		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	174.83							Fee Schedule		162.66							Fee Schedule		110.34							Fee Schedule		157.92							Fee Schedule		212.63							Fee Schedule		181.61							Fee Schedule		146.87							Fee Schedule											181.61							Fee Schedule	No services provided during 15 month lookback period	146.87							Fee Schedule		
AFO MULTI PODUS SYSTEM LA62385	274	RC	L1902	CPT				Both			759.15	341.62	70.75	683.24		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	561.77							Fee Schedule		97.22							Fee Schedule		70.75							Fee Schedule		94.39							Fee Schedule		683.24							Fee Schedule		108.55							Fee Schedule		87.78							Fee Schedule											108.55							Fee Schedule	No services provided during 15 month lookback period	87.78							Fee Schedule		
AFP MATERNAL SER 5059	301	RC	82105	CPT				Both			106.05	47.72	14.91	95.45	14.91							Fee Schedule		18.64							Fee Schedule		17.27							Fee Schedule		16.77							Fee Schedule		16.77							Fee Schedule		95.45							Fee Schedule		19.29							Fee Schedule		15.6							Fee Schedule		16.77							Fee Schedule		19.29							Fee Schedule	No services provided during 15 month lookback period	15.6							Fee Schedule		
AFP PERITONEAL FL 17410	301	RC	86316	CPT				Both			115.5	51.98	18.5	103.95	18.5							Fee Schedule		23.13							Fee Schedule		21.43							Fee Schedule		20.81							Fee Schedule		20.81							Fee Schedule		103.95							Fee Schedule		23.93							Fee Schedule		19.35							Fee Schedule		20.81							Fee Schedule		23.93							Fee Schedule	No services provided during 15 month lookback period	19.35							Fee Schedule		
AFP TUMOR MAR 237 SERUM	301	RC	82105	CPT				Both			94.5	42.53	14.91	85.05	14.91							Fee Schedule		18.64							Fee Schedule		17.27							Fee Schedule		16.77							Fee Schedule		16.77							Fee Schedule		85.05							Fee Schedule		19.29							Fee Schedule		15.6							Fee Schedule		16.77							Fee Schedule		19.29							Fee Schedule	No services provided during 15 month lookback period	15.6							Fee Schedule		
AFRIN NOSE DROPS	250	RC	A9270	CPT				Both			14.05	6.32	0.01	12.65	0.01							Fee Schedule		10.4							Fee Schedule																													12.65							Fee Schedule																																					No services provided during 15 month lookback period										
AGGRASTAT 12.5 MG/250 ML PREMIX	636	RC	J3246	CPT				Both			903	406.35	2.71	812.7		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	668.22							Fee Schedule		3							Fee Schedule											2.92							Fee Schedule		812.7							Fee Schedule		3.35							Fee Schedule		2.71							Fee Schedule											3.35							Fee Schedule	No services provided during 15 month lookback period	2.71							Fee Schedule		
AGGRASTAT 12.5 MG/50 ML (0.25 MG/ML)	636	RC	J3246	CPT				Both			945	425.25	2.71	850.5		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	699.3							Fee Schedule		3							Fee Schedule											2.92							Fee Schedule		850.5							Fee Schedule		3.35							Fee Schedule		2.71							Fee Schedule											3.35							Fee Schedule	No services provided during 15 month lookback period	2.71							Fee Schedule		
AGGRENOX 200/25 MG CAPSULE UD	250	RC	A9270	CPT				Both			35.7	16.07	0.01	32.13	0.01							Fee Schedule		26.42							Fee Schedule																													32.13							Fee Schedule																																					No services provided during 15 month lookback period										
AGGRESSIVE++ ARTHROSCOPY BLADE (STRYKER	272	RC						Both			197.4	88.83	88.83	177.66	128.31							Fee Schedule		146.08							Fee Schedule																													177.66							Fee Schedule																																					No services provided during 15 month lookback period										
AIR ELIMINATING SPIKE SET (BAXTER HEALT)	270	RC						Both			44.1	19.85	19.85	39.69	28.67							Fee Schedule		32.63							Fee Schedule																													39.69							Fee Schedule																																					No services provided during 15 month lookback period										
AIR MATTRESS	270	RC						Both			5.25	2.36	2.36	4.73	3.41							Fee Schedule		3.89							Fee Schedule																													4.73							Fee Schedule																																					No services provided during 15 month lookback period										
AIRFIT F40 CPAP MASK STARTER PACK 64611	270	RC						Both			39	17.55	17.55	35.1	25.35							Fee Schedule		28.86							Fee Schedule																													35.1							Fee Schedule																																					No services provided during 15 month lookback period										
AIRLIFE WATER TRAP 5276	271	RC						Both			6.3	2.84	2.84	5.67	4.1							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																					No services provided during 15 month lookback period										
AIRSEAL 12MM PORT/OBTURATOR IAS12-120LPI	272	RC						Both			289.17	130.13	130.13	260.25	187.96							Fee Schedule		213.99							Fee Schedule																													260.25							Fee Schedule																																					No services provided during 15 month lookback period										
AIRSEAL 5MM PORT & OBTURATOR #IAS5-120LP	272	RC						Both			276	124.2	124.2	248.4	179.4							Fee Schedule		204.24							Fee Schedule																													248.4							Fee Schedule																																					No services provided during 15 month lookback period										
AIRSEAL 8MM LONG PORT/OBTURATOR IAS8-DVL	272	RC						Both			336	151.2	151.2	302.4	218.4							Fee Schedule		248.64							Fee Schedule																													302.4							Fee Schedule																																					No services provided during 15 month lookback period										
AIRSEAL 8MM PORT & OBTURATOR  IAS8-120LP	272	RC						Both			279	125.55	125.55	251.1	181.35							Fee Schedule		206.46							Fee Schedule																													251.1							Fee Schedule																																					No services provided during 15 month lookback period										
AIRSEAL 8MM PORT & OBTURATOR  IAS8-DV	272	RC						Both			336	151.2	151.2	302.4	218.4							Fee Schedule		248.64							Fee Schedule																													302.4							Fee Schedule																																					No services provided during 15 month lookback period										
AIRSEAL BIFURCATED TUBING  ASM-EVAC1-BI	272	RC						Both			336	151.2	151.2	302.4	218.4							Fee Schedule		248.64							Fee Schedule																													302.4							Fee Schedule																																					No services provided during 15 month lookback period										
AIRSEAL PINK TUBING  ASM-EVAC1-DV	272	RC						Both			336	151.2	151.2	302.4	218.4							Fee Schedule		248.64							Fee Schedule																													302.4							Fee Schedule																																					No services provided during 15 month lookback period										
AIRSEAL TRI-LUMEN TUBING  ASM-EVAC1	272	RC						Both			289	130.05	130.05	260.1	187.85							Fee Schedule		213.86							Fee Schedule																													260.1							Fee Schedule																																					No services provided during 15 month lookback period										
AIRWAY INFANT 4CM	271	RC						Both			1.05	0.47	0.47	0.95	0.68							Fee Schedule		0.78							Fee Schedule																													0.95							Fee Schedule																																					No services provided during 15 month lookback period										
AIRWAY INFANT 5CM. #2051	271	RC						Both			1.05	0.47	0.47	0.95	0.68							Fee Schedule		0.78							Fee Schedule																													0.95							Fee Schedule																																					No services provided during 15 month lookback period										
AIRWAY LG  ADULT 11CM 1-1506-110 SHARN	271	RC						Both			1	0.45	0.45	0.9	0.65							Fee Schedule		0.74							Fee Schedule																													0.9							Fee Schedule																																					No services provided during 15 month lookback period										
AIRWAY LG. ADULT 10CM DYND60425	271	RC						Both			1	0.45	0.45	0.9	0.65							Fee Schedule		0.74							Fee Schedule																													0.9							Fee Schedule																																					No services provided during 15 month lookback period										
AIRWAY MED ADULT 9CM #1-1506-90	271	RC						Both			1	0.45	0.45	0.9	0.65							Fee Schedule		0.74							Fee Schedule																													0.9							Fee Schedule																																					No services provided during 15 month lookback period										
AIRWAY MED. ADULT 9CM #2091 (NS)	271	RC						Both			1.05	0.47	0.47	0.95	0.68							Fee Schedule		0.78							Fee Schedule																													0.95							Fee Schedule																																					No services provided during 15 month lookback period										
AIRWAY NASOPHAR. TRUMPET 32FR BRD055532	271	RC						Both			51	22.95	22.95	45.9	33.15							Fee Schedule		37.74							Fee Schedule																													45.9							Fee Schedule																																					No services provided during 15 month lookback period										
AIRWAY SM ADULT 6CM #1-1506-60	271	RC						Both			1	0.45	0.45	0.9	0.65							Fee Schedule		0.74							Fee Schedule																													0.9							Fee Schedule																																					No services provided during 15 month lookback period										
AIRWAY SM ADULT 7CM 1-1506-70	271	RC						Both			1	0.45	0.45	0.9	0.65							Fee Schedule		0.74							Fee Schedule																													0.9							Fee Schedule																																					No services provided during 15 month lookback period										
AIRWAY SM ADULT 8CM #2081	271	RC						Both			1.05	0.47	0.47	0.95	0.68							Fee Schedule		0.78							Fee Schedule																													0.95							Fee Schedule																																					No services provided during 15 month lookback period										
AIRWAY SM. CH 6CM #2061EU	271	RC						Both			1	0.45	0.45	0.9	0.65							Fee Schedule		0.74							Fee Schedule																													0.9							Fee Schedule																																					No services provided during 15 month lookback period										
AK-CON OPTH SOL	250	RC	A9270	CPT				Both			22.46	10.11	0.01	20.21	0.01							Fee Schedule		16.62							Fee Schedule																													20.21							Fee Schedule																																					No services provided during 15 month lookback period										
ALBUMIN (25%) 12.5 GM/50ML PREMIX	636	RC	P9047	CPT				Both			218.4	98.28	46.01	196.56		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	46.01							Fee Schedule		54.67							Fee Schedule		46.56							Fee Schedule		53.08							Fee Schedule		196.56							Fee Schedule		61.04							Fee Schedule		49.36							Fee Schedule											61.04							Fee Schedule	No services provided during 15 month lookback period	49.36							Fee Schedule		
ALBUMIN (25%) 25 GM/100 ML IVPB	636	RC	P9047	CPT				Both			437.85	197.03	46.01	394.07		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	46.01							Fee Schedule		54.67							Fee Schedule		46.56							Fee Schedule		53.08							Fee Schedule		394.07							Fee Schedule		61.04							Fee Schedule		49.36							Fee Schedule											61.04							Fee Schedule	No services provided during 15 month lookback period	49.36							Fee Schedule		
ALBUMIN 24 HR UR 4555	301	RC	82042	CPT				Both			210	94.5	5.6	189	5.6							Fee Schedule		7.78							Fee Schedule		8.01							Fee Schedule		7.78							Fee Schedule		7.78							Fee Schedule		189							Fee Schedule		8.95							Fee Schedule		7.24							Fee Schedule		7.78							Fee Schedule		8.95							Fee Schedule	No services provided during 15 month lookback period	7.24							Fee Schedule		
ALBUMIN BODY FLU 17412 FROZEN	301	RC	82042	CPT				Both			39.9	17.96	5.6	35.91	5.6							Fee Schedule		7.78							Fee Schedule		8.01							Fee Schedule		7.78							Fee Schedule		7.78							Fee Schedule		35.91							Fee Schedule		8.95							Fee Schedule		7.24							Fee Schedule		7.78							Fee Schedule		8.95							Fee Schedule	No services provided during 15 month lookback period	7.24							Fee Schedule		
ALBUMIN SERUM	301	RC	82040	CPT				Both			29.4	13.23	4.4	26.46	4.4							Fee Schedule		5.5							Fee Schedule		5.1							Fee Schedule		4.95							Fee Schedule		4.95							Fee Schedule		26.46							Fee Schedule		5.69							Fee Schedule		4.6							Fee Schedule		4.95							Fee Schedule		5.69							Fee Schedule	No services provided during 15 month lookback period	4.6							Fee Schedule		
"ALBUMIN, RANDOM URN WITH CREAT 6517"	301	RC	82043	CPT				Both			24	10.8	5.14	21.6	5.14							Fee Schedule		6.42							Fee Schedule		5.95							Fee Schedule		5.78							Fee Schedule		5.78							Fee Schedule		21.6							Fee Schedule		6.65							Fee Schedule		5.38							Fee Schedule		5.78							Fee Schedule		6.65							Fee Schedule	No services provided during 15 month lookback period	5.38							Fee Schedule		
ALBUTEROL 0.083%--2.5MG/3ML  AEROSOL UD	250	RC	J7613	CPT				Both			6.3	2.84	0.04	5.67	0.04							Fee Schedule		4.66							Fee Schedule		0.06							Fee Schedule											0.06							Fee Schedule		5.67							Fee Schedule		0.07							Fee Schedule		0.06							Fee Schedule											0.07							Fee Schedule	No services provided during 15 month lookback period	0.06							Fee Schedule		
ALBUTEROL 1.25MG/3ML AEROSOL UD (RT)	250	RC	J7613	CPT				Both			6.3	2.84	0.04	5.67	0.04							Fee Schedule		4.66							Fee Schedule		0.06							Fee Schedule											0.06							Fee Schedule		5.67							Fee Schedule		0.07							Fee Schedule		0.06							Fee Schedule											0.07							Fee Schedule	No services provided during 15 month lookback period	0.06							Fee Schedule		
ALBUTEROL 2 MG TABLET UD	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																					No services provided during 15 month lookback period										
ALBUTEROL 2 MG/5 ML ORAL SYRUP	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																					No services provided during 15 month lookback period										
ALBUTEROL 4MG TABLET U/D	250	RC	A9270	CPT				Both			4.2	1.89	0.01	3.78	0.01							Fee Schedule		3.11							Fee Schedule																													3.78							Fee Schedule																																					No services provided during 15 month lookback period										
ALBUTEROL 5 MG/ML 20ML FOR AEROSOL	250	RC	J7611	CPT				Both			40.95	18.43	0.22	36.86	0.24							Fee Schedule		30.3							Fee Schedule		0.24							Fee Schedule											0.23							Fee Schedule		36.86							Fee Schedule		0.27							Fee Schedule		0.22							Fee Schedule											0.27							Fee Schedule	No services provided during 15 month lookback period	0.22							Fee Schedule		
ALBUTEROL ER 4 MG REPETABS UD	250	RC	A9270	CPT				Both			4.2	1.89	0.01	3.78	0.01							Fee Schedule		3.11							Fee Schedule																													3.78							Fee Schedule																																					No services provided during 15 month lookback period										
ALC CHAIN CUSTODY 443 2 GRAY	301	RC	80307	CPT				Both			138.6	62.37	51.72	124.74	51.72							Fee Schedule		64.65							Fee Schedule		64							Fee Schedule		62.14							Fee Schedule		62.14							Fee Schedule		124.74							Fee Schedule		71.46							Fee Schedule		57.79							Fee Schedule		62.14							Fee Schedule		71.46							Fee Schedule	No services provided during 15 month lookback period	57.79							Fee Schedule		
ALC ISOPROPYL 578 GRAY TOP TUBE	301	RC	84600	CPT				Both			82.95	37.33	14.29	74.66	14.29							Fee Schedule		17.87							Fee Schedule		17.62							Fee Schedule		17.11							Fee Schedule		17.11							Fee Schedule		74.66							Fee Schedule		19.68							Fee Schedule		15.91							Fee Schedule		17.11							Fee Schedule		19.68							Fee Schedule	No services provided during 15 month lookback period	15.91							Fee Schedule		
ALCOHOL	300	RC	80307	CPT				Both			315	141.75	51.72	283.5	51.72							Fee Schedule		64.65							Fee Schedule		64							Fee Schedule		62.14							Fee Schedule		62.14							Fee Schedule		283.5							Fee Schedule		71.46							Fee Schedule		57.79							Fee Schedule		62.14							Fee Schedule		71.46							Fee Schedule	No services provided during 15 month lookback period	57.79							Fee Schedule		
ALCOHOL (BOTTLE)	270	RC						Both			4.2	1.89	1.89	3.78	2.73							Fee Schedule		3.11							Fee Schedule																													3.78							Fee Schedule																																					No services provided during 15 month lookback period										
ALCOHOL BREATH	301	RC	82075	CPT				Both			84	37.8	0.01	75.6	0.01							Fee Schedule		30							Fee Schedule		30.9							Fee Schedule		30							Fee Schedule		30							Fee Schedule		75.6							Fee Schedule		34.5							Fee Schedule		27.9							Fee Schedule		30							Fee Schedule		34.5							Fee Schedule	No services provided during 15 month lookback period	27.9							Fee Schedule		
ALCOHOL DEHYDRATED 98%-5ML AMP	250	RC						Both			137.55	61.9	61.9	123.8	89.41							Fee Schedule		101.79							Fee Schedule																													123.8							Fee Schedule																																					No services provided during 15 month lookback period										
ALCOHOL SWABSTICKS (DISC.)	272	RC	A4245	CPT				Both			4.2	1.89	1.56	3.78	1.56							Fee Schedule		3.11							Fee Schedule											3.19							Fee Schedule											3.78							Fee Schedule																																					No services provided during 15 month lookback period										
CRANIAL AND PERIPHERAL NERVE DISORDERS WITH MCC					73	DRG		Inpatient			30950.92	13927.91	13927.91	13927.91							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback				12424.73	12424.73	12424.73	1 through 10		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period	
CRANIAL AND PERIPHERAL NERVE DISORDERS WITHOUT MCC					74	DRG		Inpatient			26572.98	11957.84	11957.84	11957.84							0		No services performed during 15 month lookback period. 				9539.98	9539.98	9539.98	1 through 10									0		No services performed during 15 month lookback period				3003.9	3003.9	3003.9	1 through 10									0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period				9224.3	9224.3	9224.3	1 through 10									0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period	
NONTRAUMATIC STUPOR AND COMA WITHOUT MCC					81	DRG		Inpatient			28724.61	12926.07	12926.07	12926.07							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period	
ALDOLASE 227 SERUM	301	RC	82085	CPT				Both			60.9	27.41	8.63	54.81	8.63							Fee Schedule		10.79							Fee Schedule		10							Fee Schedule		9.71							Fee Schedule		9.71							Fee Schedule		54.81							Fee Schedule		11.17							Fee Schedule		9.03							Fee Schedule		9.71							Fee Schedule		11.17							Fee Schedule	No services provided during 15 month lookback period	9.03							Fee Schedule		
ALDOSTERONE 17181 SERUM ALDACTON	301	RC	82088	CPT				Both			264.6	119.07	36.22	238.14	36.22							Fee Schedule		45.28							Fee Schedule		41.97							Fee Schedule		40.75							Fee Schedule		40.75							Fee Schedule		238.14							Fee Schedule		46.86							Fee Schedule		37.9							Fee Schedule		40.75							Fee Schedule		46.86							Fee Schedule	No services provided during 15 month lookback period	37.9							Fee Schedule		
ALDOSTERONE 24HR URINE 229	301	RC	82088	CPT				Both			149.1	67.1	36.22	134.19	36.22							Fee Schedule		45.28							Fee Schedule		41.97							Fee Schedule		40.75							Fee Schedule		40.75							Fee Schedule		134.19							Fee Schedule		46.86							Fee Schedule		37.9							Fee Schedule		40.75							Fee Schedule		46.86							Fee Schedule	No services provided during 15 month lookback period	37.9							Fee Schedule		
ALEXIS O C-SECTION RETRACTOR LG G6313	272	RC						Both			258	116.1	116.1	232.2	167.7							Fee Schedule		190.92							Fee Schedule																													232.2							Fee Schedule																																					No services provided during 15 month lookback period										
ALEXIS WOUND RETRACTOR C8301	272	RC						Both			186	83.7	83.7	167.4	120.9							Fee Schedule		137.64							Fee Schedule																													167.4							Fee Schedule																																					No services provided during 15 month lookback period										
ALEXIS WOUND RETRACTOR C8302	272	RC						Both			186	83.7	83.7	167.4	120.9							Fee Schedule		137.64							Fee Schedule																													167.4							Fee Schedule																																					No services provided during 15 month lookback period										
ALEXIS WOUND RETRACTOR C8303	272	RC						Both			276.15	124.27	124.27	248.54	179.5							Fee Schedule		204.35							Fee Schedule																													248.54							Fee Schedule																																					No services provided during 15 month lookback period										
ALGIDEX GAUZE PADS 46-GZ22-1	623	RC	A6231	CPT				Both			7.89	3.55	3.55	7.68	4.22							Fee Schedule		5.84							Fee Schedule		6.88							Fee Schedule											6.68							Fee Schedule		7.1							Fee Schedule		7.68							Fee Schedule		6.21							Fee Schedule											7.68							Fee Schedule	No services provided during 15 month lookback period	6.21							Fee Schedule		
ALGIDEX PACKING GAUZE SILVER  46-PG14	623	RC	A6407	CPT				Both			22.05	9.92	1.64	19.85	1.69							Fee Schedule		16.32							Fee Schedule		2.74							Fee Schedule		1.64							Fee Schedule		2.66							Fee Schedule		19.85							Fee Schedule		3.06							Fee Schedule		2.47							Fee Schedule											3.06							Fee Schedule	No services provided during 15 month lookback period	2.47							Fee Schedule		
ALGIDEX PASTE 46-P10	272	RC	A6248	CPT				Both			24.15	10.87	10.87	26.62	14.63							Fee Schedule		17.87							Fee Schedule		23.84							Fee Schedule		18.29							Fee Schedule		23.15							Fee Schedule		21.74							Fee Schedule		26.62							Fee Schedule		21.53							Fee Schedule											26.62							Fee Schedule	No services provided during 15 month lookback period	21.53							Fee Schedule		
ALGY ACACIA GUM IGE 2519 2ML SERUM	302	RC	86003	CPT				Both			109.2	49.14	4.64	98.28	4.64							Fee Schedule		5.8							Fee Schedule		5.38							Fee Schedule		5.22							Fee Schedule		5.22							Fee Schedule		98.28							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		5.22							Fee Schedule		6							Fee Schedule	No services provided during 15 month lookback period	4.85							Fee Schedule		
ALGY ALDER IGE 2502 0.3 ML SERUM	302	RC	86003	CPT				Both			31.5	14.18	4.64	28.35	4.64							Fee Schedule		5.8							Fee Schedule		5.38							Fee Schedule		5.22							Fee Schedule		5.22							Fee Schedule		28.35							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		5.22							Fee Schedule		6							Fee Schedule	No services provided during 15 month lookback period	4.85							Fee Schedule		
ALGY ALLSPICE 39498   1 ML SERUM RM TM	302	RC	86003	CPT				Both			31.5	14.18	4.64	28.35	4.64							Fee Schedule		5.8							Fee Schedule		5.38							Fee Schedule		5.22							Fee Schedule		5.22							Fee Schedule		28.35							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		5.22							Fee Schedule		6							Fee Schedule	No services provided during 15 month lookback period	4.85							Fee Schedule		
ALGY ALMOND IGE 2820 0.5 ML SERUM	302	RC	86003	CPT				Both			31.5	14.18	4.64	28.35	4.64							Fee Schedule		5.8							Fee Schedule		5.38							Fee Schedule		5.22							Fee Schedule		5.22							Fee Schedule		28.35							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		5.22							Fee Schedule		6							Fee Schedule	No services provided during 15 month lookback period	4.85							Fee Schedule		
ALGY ALTERNARIA IGE 2706 ALTEMATA MOLD	302	RC	86003	CPT				Both			31.5	14.18	4.64	28.35	4.64							Fee Schedule		5.8							Fee Schedule		5.38							Fee Schedule		5.22							Fee Schedule		5.22							Fee Schedule		28.35							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		5.22							Fee Schedule		6							Fee Schedule	No services provided during 15 month lookback period	4.85							Fee Schedule		
ALGY APPLE IGE 2849 2 ML SERUM	302	RC	86003	CPT				Both			31.5	14.18	4.64	28.35	4.64							Fee Schedule		5.8							Fee Schedule		5.38							Fee Schedule		5.22							Fee Schedule		5.22							Fee Schedule		28.35							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		5.22							Fee Schedule		6							Fee Schedule	No services provided during 15 month lookback period	4.85							Fee Schedule		
ALGY APRICOT IGE 2563  1ML SERUM RM TM	302	RC	86003	CPT				Both			52.5	23.63	4.64	47.25	4.64							Fee Schedule		5.8							Fee Schedule		5.38							Fee Schedule		5.22							Fee Schedule		5.22							Fee Schedule		47.25							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		5.22							Fee Schedule		6							Fee Schedule	No services provided during 15 month lookback period	4.85							Fee Schedule		
ALGY ASPARAGUS IGE 2626 0.3ML SER RT	302	RC	86003	CPT				Both			52.5	23.63	4.64	47.25	4.64							Fee Schedule		5.8							Fee Schedule		5.38							Fee Schedule		5.22							Fee Schedule		5.22							Fee Schedule		47.25							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		5.22							Fee Schedule		6							Fee Schedule	No services provided during 15 month lookback period	4.85							Fee Schedule		
ALGY ASPERGILLUS FUMIGATUS IGG 30163 1ML	302	RC	86003	CPT				Both			52.5	23.63	4.64	47.25	4.64							Fee Schedule		5.8							Fee Schedule		5.38							Fee Schedule		5.22							Fee Schedule		5.22							Fee Schedule		47.25							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		5.22							Fee Schedule		6							Fee Schedule	No services provided during 15 month lookback period	4.85							Fee Schedule		
ALGY ASPERGILLUS FUMIGATUS IGG 30163 1ML	302	RC	86001	CPT				Both			52.5	23.63	5.63	47.25	5.63							Fee Schedule		7.82							Fee Schedule		8.05							Fee Schedule		7.82							Fee Schedule		7.82							Fee Schedule		47.25							Fee Schedule		8.99							Fee Schedule		7.27							Fee Schedule		7.82							Fee Schedule		8.99							Fee Schedule	No services provided during 15 month lookback period	7.27							Fee Schedule		
ALGY ASPERGILLUS FUMIGATUS MOLD IGE 2703	302	RC	86003	CPT				Both			45.15	20.32	4.64	40.64	4.64							Fee Schedule		5.8							Fee Schedule		5.38							Fee Schedule		5.22							Fee Schedule		5.22							Fee Schedule		40.64							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		5.22							Fee Schedule		6							Fee Schedule	No services provided during 15 month lookback period	4.85							Fee Schedule		
ALGY AVOCADO IGG 10639 0.5 ML SER RT	302	RC	86001	CPT				Both			52.5	23.63	5.63	47.25	5.63							Fee Schedule		7.82							Fee Schedule		8.05							Fee Schedule		7.82							Fee Schedule		7.82							Fee Schedule		47.25							Fee Schedule		8.99							Fee Schedule		7.27							Fee Schedule		7.82							Fee Schedule		8.99							Fee Schedule	No services provided during 15 month lookback period	7.27							Fee Schedule		
ALGY BAHIA GRASS IGE 2317 0.3 ML SERUM	302	RC	86003	CPT				Both			31.5	14.18	4.64	28.35	4.64							Fee Schedule		5.8							Fee Schedule		5.38							Fee Schedule		5.22							Fee Schedule		5.22							Fee Schedule		28.35							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		5.22							Fee Schedule		6							Fee Schedule	No services provided during 15 month lookback period	4.85							Fee Schedule		
ALGY BANANA IGE 8926 2ML SERUM	302	RC	86003	CPT				Both			31.5	14.18	4.64	28.35	4.64							Fee Schedule		5.8							Fee Schedule		5.38							Fee Schedule		5.22							Fee Schedule		5.22							Fee Schedule		28.35							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		5.22							Fee Schedule		6							Fee Schedule	No services provided during 15 month lookback period	4.85							Fee Schedule		
ALGY BARLEY  IGE 2806  0.3 ML SERUM RT	302	RC	86003	CPT				Both			31.5	14.18	4.64	28.35	4.64							Fee Schedule		5.8							Fee Schedule		5.38							Fee Schedule		5.22							Fee Schedule		5.22							Fee Schedule		28.35							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		5.22							Fee Schedule		6							Fee Schedule	No services provided during 15 month lookback period	4.85							Fee Schedule		
ALGY BASIL IGE 2564 0.3ML SER RT	302	RC	86003	CPT				Both			52.5	23.63	4.64	47.25	4.64							Fee Schedule		5.8							Fee Schedule		5.38							Fee Schedule		5.22							Fee Schedule		5.22							Fee Schedule		47.25							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		5.22							Fee Schedule		6							Fee Schedule	No services provided during 15 month lookback period	4.85							Fee Schedule		
ALGY BAY LEAF IGE 2628 0.3ML SER RT	302	RC	86003	CPT				Both			52.5	23.63	4.64	47.25	4.64							Fee Schedule		5.8							Fee Schedule		5.38							Fee Schedule		5.22							Fee Schedule		5.22							Fee Schedule		47.25							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		5.22							Fee Schedule		6							Fee Schedule	No services provided during 15 month lookback period	4.85							Fee Schedule		
ALGY BEEF IGE 2827 0.5 ML SERUM	302	RC	86003	CPT				Both			31.5	14.18	4.64	28.35	4.64							Fee Schedule		5.8							Fee Schedule		5.38							Fee Schedule		5.22							Fee Schedule		5.22							Fee Schedule		28.35							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		5.22							Fee Schedule		6							Fee Schedule	No services provided during 15 month lookback period	4.85							Fee Schedule		
ALGY BERMUDA GRA IGE 2302 0.3ML SERUM	302	RC	86003	CPT				Both			31.5	14.18	4.64	28.35	4.64							Fee Schedule		5.8							Fee Schedule		5.38							Fee Schedule		5.22							Fee Schedule		5.22							Fee Schedule		28.35							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		5.22							Fee Schedule		6							Fee Schedule	No services provided during 15 month lookback period	4.85							Fee Schedule		
ALGY BIRCH IGE 2503 0.3 ML SER	302	RC	86003	CPT				Both			31.5	14.18	4.64	28.35	4.64							Fee Schedule		5.8							Fee Schedule		5.38							Fee Schedule		5.22							Fee Schedule		5.22							Fee Schedule		28.35							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		5.22							Fee Schedule		6							Fee Schedule	No services provided during 15 month lookback period	4.85							Fee Schedule		
ALGY BLACK PEPPER IGG 17082 0.3 ML SE RT	302	RC	86001	CPT				Both			52.5	23.63	5.63	47.25	5.63							Fee Schedule		7.82							Fee Schedule		8.05							Fee Schedule		7.82							Fee Schedule		7.82							Fee Schedule		47.25							Fee Schedule		8.99							Fee Schedule		7.27							Fee Schedule		7.82							Fee Schedule		8.99							Fee Schedule	No services provided during 15 month lookback period	7.27							Fee Schedule		
ALGY BLACK WALNUT IGE 3489	302	RC	86003	CPT				Both			55.65	25.04	4.64	50.09	4.64							Fee Schedule		5.8							Fee Schedule		5.38							Fee Schedule		5.22							Fee Schedule		5.22							Fee Schedule		50.09							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		5.22							Fee Schedule		6							Fee Schedule	No services provided during 15 month lookback period	4.85							Fee Schedule		
ALGY BLACKBERRY (f211)  IGE 2630	302	RC	86003	CPT				Both			31.5	14.18	4.64	28.35	4.64							Fee Schedule		5.8							Fee Schedule		5.38							Fee Schedule		5.22							Fee Schedule		5.22							Fee Schedule		28.35							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		5.22							Fee Schedule		6							Fee Schedule	No services provided during 15 month lookback period	4.85							Fee Schedule		
ALGY BLUEBERRY IGE 2568 1.0 ML SERUM	302	RC	86003	CPT				Both			31.5	14.18	4.64	28.35	4.64							Fee Schedule		5.8							Fee Schedule		5.38							Fee Schedule		5.22							Fee Schedule		5.22							Fee Schedule		28.35							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		5.22							Fee Schedule		6							Fee Schedule	No services provided during 15 month lookback period	4.85							Fee Schedule		
ALGY BOTRYTIS CINEREA 6647    0.3 ML SE	302	RC	86003	CPT				Both			31.5	14.18	4.64	28.35	4.64							Fee Schedule		5.8							Fee Schedule		5.38							Fee Schedule		5.22							Fee Schedule		5.22							Fee Schedule		28.35							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		5.22							Fee Schedule		6							Fee Schedule	No services provided during 15 month lookback period	4.85							Fee Schedule		
ALGY BRAZIL NUT 2818  0.3 ML SERUM	302	RC	86003	CPT				Both			45.15	20.32	4.64	40.64	4.64							Fee Schedule		5.8							Fee Schedule		5.38							Fee Schedule		5.22							Fee Schedule		5.22							Fee Schedule		40.64							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		5.22							Fee Schedule		6							Fee Schedule	No services provided during 15 month lookback period	4.85							Fee Schedule		
ALGY BROCCOLI  IGE 2631  0.3 ML SERUM RT	302	RC	86003	CPT				Both			31.5	14.18	4.64	28.35	4.64							Fee Schedule		5.8							Fee Schedule		5.38							Fee Schedule		5.22							Fee Schedule		5.22							Fee Schedule		28.35							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		5.22							Fee Schedule		6							Fee Schedule	No services provided during 15 month lookback period	4.85							Fee Schedule		
ALGY BUCKWHEAT IGE 2811 1 ML SERUM RM TM	302	RC	86003	CPT				Both			31.5	14.18	4.64	28.35	4.64							Fee Schedule		5.8							Fee Schedule		5.38							Fee Schedule		5.22							Fee Schedule		5.22							Fee Schedule		28.35							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		5.22							Fee Schedule		6							Fee Schedule	No services provided during 15 month lookback period	4.85							Fee Schedule		
ALGY CABBAGE IGG 38118 0.5 ML SER RT	302	RC	86003	CPT				Both			52.5	23.63	4.64	47.25	4.64							Fee Schedule		5.8							Fee Schedule		5.38							Fee Schedule		5.22							Fee Schedule		5.22							Fee Schedule		47.25							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		5.22							Fee Schedule		6							Fee Schedule	No services provided during 15 month lookback period	4.85							Fee Schedule		
ALGY CANDIDA ALBICANS IGE 2705 0.3ML SER	302	RC	86003	CPT				Both			45.15	20.32	4.64	40.64	4.64							Fee Schedule		5.8							Fee Schedule		5.38							Fee Schedule		5.22							Fee Schedule		5.22							Fee Schedule		40.64							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		5.22							Fee Schedule		6							Fee Schedule	No services provided during 15 month lookback period	4.85							Fee Schedule		
ALGY CANTALOUPE IGE 14972 0.5ML SER RT	302	RC	86003	CPT				Both			52.5	23.63	4.64	47.25	4.64							Fee Schedule		5.8							Fee Schedule		5.38							Fee Schedule		5.22							Fee Schedule		5.22							Fee Schedule		47.25							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		5.22							Fee Schedule		6							Fee Schedule	No services provided during 15 month lookback period	4.85							Fee Schedule		
ALGY CARROT IGE 2831 1ML SERUM RM TM	302	RC	86003	CPT				Both			31.5	14.18	4.64	28.35	4.64							Fee Schedule		5.8							Fee Schedule		5.38							Fee Schedule		5.22							Fee Schedule		5.22							Fee Schedule		28.35							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		5.22							Fee Schedule		6							Fee Schedule	No services provided during 15 month lookback period	4.85							Fee Schedule		
ALGY CASEIN FOOD IGE 2853 0.5 ML SERUM	302	RC	86003	CPT				Both			31.5	14.18	4.64	28.35	4.64							Fee Schedule		5.8							Fee Schedule		5.38							Fee Schedule		5.22							Fee Schedule		5.22							Fee Schedule		28.35							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		5.22							Fee Schedule		6							Fee Schedule	No services provided during 15 month lookback period	4.85							Fee Schedule		
ALGY CASHEW NUT IGE 2608 0.5 ML SERUM	302	RC	86003	CPT				Both			31.5	14.18	4.64	28.35	4.64							Fee Schedule		5.8							Fee Schedule		5.38							Fee Schedule		5.22							Fee Schedule		5.22							Fee Schedule		28.35							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		5.22							Fee Schedule		6							Fee Schedule	No services provided during 15 month lookback period	4.85							Fee Schedule		
ALGY CAT DANDER IGE 2601 1ML SERUM	302	RC	86003	CPT				Both			31.5	14.18	4.64	28.35	4.64							Fee Schedule		5.8							Fee Schedule		5.38							Fee Schedule		5.22							Fee Schedule		5.22							Fee Schedule		28.35							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		5.22							Fee Schedule		6							Fee Schedule	No services provided during 15 month lookback period	4.85							Fee Schedule		
ALGY CATFISH (f369) IGE 38267	302	RC	86003	CPT				Both			42	18.9	4.64	37.8	4.64							Fee Schedule		5.8							Fee Schedule		5.38							Fee Schedule		5.22							Fee Schedule		5.22							Fee Schedule		37.8							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		5.22							Fee Schedule		6							Fee Schedule	No services provided during 15 month lookback period	4.85							Fee Schedule		
ALGY CAULIFLOWER IGE 2635 0.3ML SERUM RT	302	RC	86003	CPT				Both			36.75	16.54	4.64	33.08	4.64							Fee Schedule		5.8							Fee Schedule		5.38							Fee Schedule		5.22							Fee Schedule		5.22							Fee Schedule		33.08							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		5.22							Fee Schedule		6							Fee Schedule	No services provided during 15 month lookback period	4.85							Fee Schedule		
ALGY CELERY IGE 2860 1 ML SERUM RM TM	302	RC	86003	CPT				Both			31.5	14.18	4.64	28.35	4.64							Fee Schedule		5.8							Fee Schedule		5.38							Fee Schedule		5.22							Fee Schedule		5.22							Fee Schedule		28.35							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		5.22							Fee Schedule		6							Fee Schedule	No services provided during 15 month lookback period	4.85							Fee Schedule		
ALGY CHEDDAR CHEESE IGE 2858 0.3ML SE RT	302	RC	86003	CPT				Both			36.75	16.54	4.64	33.08	4.64							Fee Schedule		5.8							Fee Schedule		5.38							Fee Schedule		5.22							Fee Schedule		5.22							Fee Schedule		33.08							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		5.22							Fee Schedule		6							Fee Schedule	No services provided during 15 month lookback period	4.85							Fee Schedule		
ALGY CHERRY  IGE 2609  0.3 ML SERUM RT	302	RC	86003	CPT				Both			31.5	14.18	4.64	28.35	4.64							Fee Schedule		5.8							Fee Schedule		5.38							Fee Schedule		5.22							Fee Schedule		5.22							Fee Schedule		28.35							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		5.22							Fee Schedule		6							Fee Schedule	No services provided during 15 month lookback period	4.85							Fee Schedule		
ALGY CHICKEN IGE 2857 0.5 ML SERUM	302	RC	86003	CPT				Both			31.5	14.18	4.64	28.35	4.64							Fee Schedule		5.8							Fee Schedule		5.38							Fee Schedule		5.22							Fee Schedule		5.22							Fee Schedule		28.35							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		5.22							Fee Schedule		6							Fee Schedule	No services provided during 15 month lookback period	4.85							Fee Schedule		
ALGY CINNAMON IGE 2637 0.3ML SERUM RM TM	302	RC	86003	CPT				Both			52.5	23.63	4.64	47.25	4.64							Fee Schedule		5.8							Fee Schedule		5.38							Fee Schedule		5.22							Fee Schedule		5.22							Fee Schedule		47.25							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		5.22							Fee Schedule		6							Fee Schedule	No services provided during 15 month lookback period	4.85							Fee Schedule		
ALGY CLADOSPORIUM HERBARUM IGE 2702 SER	302	RC	86003	CPT				Both			31.5	14.18	4.64	28.35	4.64							Fee Schedule		5.8							Fee Schedule		5.38							Fee Schedule		5.22							Fee Schedule		5.22							Fee Schedule		28.35							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		5.22							Fee Schedule		6							Fee Schedule	No services provided during 15 month lookback period	4.85							Fee Schedule		
ALGY CLAM IGE 8929 2ML SERUM	302	RC	86003	CPT				Both			31.5	14.18	4.64	28.35	4.64							Fee Schedule		5.8							Fee Schedule		5.38							Fee Schedule		5.22							Fee Schedule		5.22							Fee Schedule		28.35							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		5.22							Fee Schedule		6							Fee Schedule	No services provided during 15 month lookback period	4.85							Fee Schedule		
ALGY CLOVE F140 IGE 1ML SERUM RM TM	302	RC	86003	CPT				Both			31.5	14.18	4.64	28.35	4.64							Fee Schedule		5.8							Fee Schedule		5.38							Fee Schedule		5.22							Fee Schedule		5.22							Fee Schedule		28.35							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		5.22							Fee Schedule		6							Fee Schedule	No services provided during 15 month lookback period	4.85							Fee Schedule		
ALGY COCKROACH IGE 2736 1.0 ML SERUM	302	RC	86003	CPT				Both			31.5	14.18	4.64	28.35	4.64							Fee Schedule		5.8							Fee Schedule		5.38							Fee Schedule		5.22							Fee Schedule		5.22							Fee Schedule		28.35							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		5.22							Fee Schedule		6							Fee Schedule	No services provided during 15 month lookback period	4.85							Fee Schedule		
ALGY COCOA IGE 2875 0.3ML SERUM RM TM	302	RC	86003	CPT				Both			31.5	14.18	4.64	28.35	4.64							Fee Schedule		5.8							Fee Schedule		5.38							Fee Schedule		5.22							Fee Schedule		5.22							Fee Schedule		28.35							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		5.22							Fee Schedule		6							Fee Schedule	No services provided during 15 month lookback period	4.85							Fee Schedule		
ALGY COCONUT IGE 2836 1ML SERUM RM TM	302	RC	86003	CPT				Both			31.5	14.18	4.64	28.35	4.64							Fee Schedule		5.8							Fee Schedule		5.38							Fee Schedule		5.22							Fee Schedule		5.22							Fee Schedule		28.35							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		5.22							Fee Schedule		6							Fee Schedule	No services provided during 15 month lookback period	4.85							Fee Schedule		
ALGY CODFISH IGE 2803 1 ML SERUM RM TM	302	RC	86003	CPT				Both			31.5	14.18	4.64	28.35	4.64							Fee Schedule		5.8							Fee Schedule		5.38							Fee Schedule		5.22							Fee Schedule		5.22							Fee Schedule		28.35							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		5.22							Fee Schedule		6							Fee Schedule	No services provided during 15 month lookback period	4.85							Fee Schedule		
ALGY COFFEE IGG 2915 1ML SERUM RM TM	302	RC	86003	CPT				Both			31.5	14.18	4.64	28.35	4.64							Fee Schedule		5.8							Fee Schedule		5.38							Fee Schedule		5.22							Fee Schedule		5.22							Fee Schedule		28.35							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		5.22							Fee Schedule		6							Fee Schedule	No services provided during 15 month lookback period	4.85							Fee Schedule		
ALGY COLA NUT IGE 37456 0.5ML SER RT	302	RC	86003	CPT				Both			52.5	23.63	4.64	47.25	4.64							Fee Schedule		5.8							Fee Schedule		5.38							Fee Schedule		5.22							Fee Schedule		5.22							Fee Schedule		47.25							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		5.22							Fee Schedule		6							Fee Schedule	No services provided during 15 month lookback period	4.85							Fee Schedule		
ALGY CORN IGE 2808 0.3ML SERUM RM TM	302	RC	86003	CPT				Both			31.5	14.18	4.64	28.35	4.64							Fee Schedule		5.8							Fee Schedule		5.38							Fee Schedule		5.22							Fee Schedule		5.22							Fee Schedule		28.35							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		5.22							Fee Schedule		6							Fee Schedule	No services provided during 15 month lookback period	4.85							Fee Schedule		
ALGY COTTAGE CHEESE IGE 38412 0.5ML S RT	302	RC	86003	CPT				Both			36.75	16.54	4.64	33.08	4.64							Fee Schedule		5.8							Fee Schedule		5.38							Fee Schedule		5.22							Fee Schedule		5.22							Fee Schedule		33.08							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		5.22							Fee Schedule		6							Fee Schedule	No services provided during 15 month lookback period	4.85							Fee Schedule		
ALGY COTTON IGE 0.5 ML SER 23862	302	RC	86003	CPT				Both			36.75	16.54	4.64	33.08	4.64							Fee Schedule		5.8							Fee Schedule		5.38							Fee Schedule		5.22							Fee Schedule		5.22							Fee Schedule		33.08							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		5.22							Fee Schedule		6							Fee Schedule	No services provided during 15 month lookback period	4.85							Fee Schedule		
ALGY COTTONWOOD POPLAR IGE 2514 0.3ML SE	302	RC	86003	CPT				Both			45.15	20.32	4.64	40.64	4.64							Fee Schedule		5.8							Fee Schedule		5.38							Fee Schedule		5.22							Fee Schedule		5.22							Fee Schedule		40.64							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		5.22							Fee Schedule		6							Fee Schedule	No services provided during 15 month lookback period	4.85							Fee Schedule		
ALGY COW'S MILK IGE 2802	302	RC	86003	CPT				Both			31.5	14.18	4.64	28.35	4.64							Fee Schedule		5.8							Fee Schedule		5.38							Fee Schedule		5.22							Fee Schedule		5.22							Fee Schedule		28.35							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		5.22							Fee Schedule		6							Fee Schedule	No services provided during 15 month lookback period	4.85							Fee Schedule		
ALGY COW'S MILK IGE W REFX 37900	302	RC	86003	CPT				Both			18	8.1	4.64	16.2	4.64							Fee Schedule		5.8							Fee Schedule		5.38							Fee Schedule		5.22							Fee Schedule		5.22							Fee Schedule		16.2							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		5.22							Fee Schedule		6							Fee Schedule	No services provided during 15 month lookback period	4.85							Fee Schedule		
ALGY CRAB IGE 2823 1 ML SERUM RM TM	302	RC	86003	CPT				Both			31.5	14.18	4.64	28.35	4.64							Fee Schedule		5.8							Fee Schedule		5.38							Fee Schedule		5.22							Fee Schedule		5.22							Fee Schedule		28.35							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		5.22							Fee Schedule		6							Fee Schedule	No services provided during 15 month lookback period	4.85							Fee Schedule		
ALGY CUCUMBER  IGE 2639  0.3 ML SERUM RT	302	RC	86003	CPT				Both			31.5	14.18	4.64	28.35	4.64							Fee Schedule		5.8							Fee Schedule		5.38							Fee Schedule		5.22							Fee Schedule		5.22							Fee Schedule		28.35							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		5.22							Fee Schedule		6							Fee Schedule	No services provided during 15 month lookback period	4.85							Fee Schedule		
ALGY CURVULARIA LUNATA IGE 6680 0.3 ML S	302	RC	86003	CPT				Both			31.5	14.18	4.64	28.35	4.64							Fee Schedule		5.8							Fee Schedule		5.38							Fee Schedule		5.22							Fee Schedule		5.22							Fee Schedule		28.35							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		5.22							Fee Schedule		6							Fee Schedule	No services provided during 15 month lookback period	4.85							Fee Schedule		
ALGY DERMATOPHAGOIDES FARINAE IGE 2722	302	RC	86003	CPT				Both			45.15	20.32	4.64	40.64	4.64							Fee Schedule		5.8							Fee Schedule		5.38							Fee Schedule		5.22							Fee Schedule		5.22							Fee Schedule		40.64							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		5.22							Fee Schedule		6							Fee Schedule	No services provided during 15 month lookback period	4.85							Fee Schedule		
ALGY DERMATOPHAGOIDES PTERONYSS IGE 2721	302	RC	86003	CPT				Both			45.15	20.32	4.64	40.64	4.64							Fee Schedule		5.8							Fee Schedule		5.38							Fee Schedule		5.22							Fee Schedule		5.22							Fee Schedule		40.64							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		5.22							Fee Schedule		6							Fee Schedule	No services provided during 15 month lookback period	4.85							Fee Schedule		
ALGY DILL IGE 2918 0.3ML SER RT	302	RC	86003	CPT				Both			52.5	23.63	4.64	47.25	4.64							Fee Schedule		5.8							Fee Schedule		5.38							Fee Schedule		5.22							Fee Schedule		5.22							Fee Schedule		47.25							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		5.22							Fee Schedule		6							Fee Schedule	No services provided during 15 month lookback period	4.85							Fee Schedule		
ALGY DOG DANDER 2605 1ML SERUM	302	RC	86003	CPT				Both			31.5	14.18	4.64	28.35	4.64							Fee Schedule		5.8							Fee Schedule		5.38							Fee Schedule		5.22							Fee Schedule		5.22							Fee Schedule		28.35							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		5.22							Fee Schedule		6							Fee Schedule	No services provided during 15 month lookback period	4.85							Fee Schedule		
ALGY DUST IGE 2711 0.3 ML SERUM	302	RC	86003	CPT				Both			31.5	14.18	4.64	28.35	4.64							Fee Schedule		5.8							Fee Schedule		5.38							Fee Schedule		5.22							Fee Schedule		5.22							Fee Schedule		28.35							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		5.22							Fee Schedule		6							Fee Schedule	No services provided during 15 month lookback period	4.85							Fee Schedule		
ALGY DUST MITE 1 IGE 2722 0.3ML SER  RT	302	RC	86003	CPT				Both			31.5	14.18	4.64	28.35	4.64							Fee Schedule		5.8							Fee Schedule		5.38							Fee Schedule		5.22							Fee Schedule		5.22							Fee Schedule		28.35							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		5.22							Fee Schedule		6							Fee Schedule	No services provided during 15 month lookback period	4.85							Fee Schedule		
ALGY DUST MITE 2 IGE 2721 0.3ML SER  RT	302	RC	86003	CPT				Both			31.5	14.18	4.64	28.35	4.64							Fee Schedule		5.8							Fee Schedule		5.38							Fee Schedule		5.22							Fee Schedule		5.22							Fee Schedule		28.35							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		5.22							Fee Schedule		6							Fee Schedule	No services provided during 15 month lookback period	4.85							Fee Schedule		
ALGY EGG WHITE IGE 2801 1 ML SERUM RM TM	302	RC	86003	CPT				Both			31.5	14.18	4.64	28.35	4.64							Fee Schedule		5.8							Fee Schedule		5.38							Fee Schedule		5.22							Fee Schedule		5.22							Fee Schedule		28.35							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		5.22							Fee Schedule		6							Fee Schedule	No services provided during 15 month lookback period	4.85							Fee Schedule		
ALGY EGG YOLK IGE 2856 1ML SERUM RM TM	302	RC	86003	CPT				Both			31.5	14.18	4.64	28.35	4.64							Fee Schedule		5.8							Fee Schedule		5.38							Fee Schedule		5.22							Fee Schedule		5.22							Fee Schedule		28.35							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		5.22							Fee Schedule		6							Fee Schedule	No services provided during 15 month lookback period	4.85							Fee Schedule		
ALGY EGGPLANT IGE 2642 0.3ML SERUM RT	302	RC	86003	CPT				Both			36.75	16.54	4.64	33.08	4.64							Fee Schedule		5.8							Fee Schedule		5.38							Fee Schedule		5.22							Fee Schedule		5.22							Fee Schedule		33.08							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		5.22							Fee Schedule		6							Fee Schedule	No services provided during 15 month lookback period	4.85							Fee Schedule		
ALGY ELM IGE 2508 0.3ML SERUM	302	RC	86003	CPT				Both			45.15	20.32	4.64	40.64	4.64							Fee Schedule		5.8							Fee Schedule		5.38							Fee Schedule		5.22							Fee Schedule		5.22							Fee Schedule		40.64							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		5.22							Fee Schedule		6							Fee Schedule	No services provided during 15 month lookback period	4.85							Fee Schedule		
ALGY ENGLISH PLANTAIN IGE 2409 0.3ML SE	302	RC	86003	CPT				Both			45.15	20.32	4.64	40.64	4.64							Fee Schedule		5.8							Fee Schedule		5.38							Fee Schedule		5.22							Fee Schedule		5.22							Fee Schedule		40.64							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		5.22							Fee Schedule		6							Fee Schedule	No services provided during 15 month lookback period	4.85							Fee Schedule		
ALGY EPICOCCUM PURPURA SCENS IGE 6692	302	RC	86003	CPT				Both			31.5	14.18	4.64	28.35	4.64							Fee Schedule		5.8							Fee Schedule		5.38							Fee Schedule		5.22							Fee Schedule		5.22							Fee Schedule		28.35							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		5.22							Fee Schedule		6							Fee Schedule	No services provided during 15 month lookback period	4.85							Fee Schedule		
ALGY FEATHERS IGE 37508 0.3 ML SERUM	302	RC	86003	CPT				Both			45.15	20.32	4.64	40.64	4.64							Fee Schedule		5.8							Fee Schedule		5.38							Fee Schedule		5.22							Fee Schedule		5.22							Fee Schedule		40.64							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		5.22							Fee Schedule		6							Fee Schedule	No services provided during 15 month lookback period	4.85							Fee Schedule		
ALGY FIRE ANT IgE 2739  SERUM	302	RC	86003	CPT				Both			31.5	14.18	4.64	28.35	4.64							Fee Schedule		5.8							Fee Schedule		5.38							Fee Schedule		5.22							Fee Schedule		5.22							Fee Schedule		28.35							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		5.22							Fee Schedule		6							Fee Schedule	No services provided during 15 month lookback period	4.85							Fee Schedule		
ALGY FISH COD IGE 2803  0.3ML SERUM	302	RC	86003	CPT				Both			45.15	20.32	4.64	40.64	4.64							Fee Schedule		5.8							Fee Schedule		5.38							Fee Schedule		5.22							Fee Schedule		5.22							Fee Schedule		40.64							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		5.22							Fee Schedule		6							Fee Schedule	No services provided during 15 month lookback period	4.85							Fee Schedule		
ALGY FLONDER IGE 23893  0.3ML SERUM RT	302	RC	86003	CPT				Both			45.15	20.32	4.64	40.64	4.64							Fee Schedule		5.8							Fee Schedule		5.38							Fee Schedule		5.22							Fee Schedule		5.22							Fee Schedule		40.64							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		5.22							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		
ALGY FOOD & TREE NUT PNL 36762	300	RC	86003	CPT				Both			30	13.5	4.64	27	4.64							Fee Schedule		5.8							Fee Schedule		5.38							Fee Schedule		5.22							Fee Schedule		5.22							Fee Schedule		27							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		5.22							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		
ALGY FUSARIUM IGE 6696 0.3 ML SERUM	302	RC	86003	CPT				Both			45.15	20.32	4.64	40.64	4.64							Fee Schedule		5.8							Fee Schedule		5.38							Fee Schedule		5.22							Fee Schedule		5.22							Fee Schedule		40.64							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		5.22							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		
ALGY GALACTOSE-ALPHA IGE 10554 1 ML SER	300	RC	86008	CPT				Both			78.75	35.44	15.94	70.88	15.94							Fee Schedule		19.93							Fee Schedule		18.47							Fee Schedule		17.93							Fee Schedule		17.93							Fee Schedule		70.88							Fee Schedule		20.62							Fee Schedule		16.67							Fee Schedule		17.93							Fee Schedule		20.62							Fee Schedule		16.67							Fee Schedule		
ALGY GARLIC IGE 2847 0.3ML SERUM RM TM	302	RC	86003	CPT				Both			31.5	14.18	4.64	28.35	4.64							Fee Schedule		5.8							Fee Schedule		5.38							Fee Schedule		5.22							Fee Schedule		5.22							Fee Schedule		28.35							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		5.22							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		
ALGY GINGER IGE 2644 0.3ML SERUM RM TM	302	RC	86003	CPT				Both			90.3	40.64	4.64	81.27	4.64							Fee Schedule		5.8							Fee Schedule		5.38							Fee Schedule		5.22							Fee Schedule		5.22							Fee Schedule		81.27							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		5.22							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		
ALGY GLUTEN IGE 2854 1 ML SERUM RM TM	302	RC	86003	CPT				Both			31.5	14.18	4.64	28.35	4.64							Fee Schedule		5.8							Fee Schedule		5.38							Fee Schedule		5.22							Fee Schedule		5.22							Fee Schedule		28.35							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		5.22							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		
ALGY GOLDEN ROD IGE 2412 0.3 ML SER	302	RC	86003	CPT				Both			31.5	14.18	4.64	28.35	4.64							Fee Schedule		5.8							Fee Schedule		5.38							Fee Schedule		5.22							Fee Schedule		5.22							Fee Schedule		28.35							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		5.22							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		
ALGY GRAPEFRUIT IGE 2923 1ML SERUM RM TM	302	RC	86003	CPT				Both			31.5	14.18	4.64	28.35	4.64							Fee Schedule		5.8							Fee Schedule		5.38							Fee Schedule		5.22							Fee Schedule		5.22							Fee Schedule		28.35							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		5.22							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		
ALGY GRAPES IGE 2675 1ML SERUM RM TM	302	RC	86003	CPT				Both			52.5	23.63	4.64	47.25	4.64							Fee Schedule		5.8							Fee Schedule		5.38							Fee Schedule		5.22							Fee Schedule		5.22							Fee Schedule		47.25							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		5.22							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		
ALGY GREEN BEAN IGE 2680 0.3ML SERUM RT	302	RC	86003	CPT				Both			36.75	16.54	4.64	33.08	4.64							Fee Schedule		5.8							Fee Schedule		5.38							Fee Schedule		5.22							Fee Schedule		5.22							Fee Schedule		33.08							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		5.22							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		
ALGY GREEN PEPPER 2931 0.3ML SERUM RT	302	RC	86003	CPT				Both			36.75	16.54	4.64	33.08	4.64							Fee Schedule		5.8							Fee Schedule		5.38							Fee Schedule		5.22							Fee Schedule		5.22							Fee Schedule		33.08							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		5.22							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		
ALGY GUAR BEAN GUM (f246)  IGE 2682	302	RC	86003	CPT				Both			31.5	14.18	4.64	28.35	4.64							Fee Schedule		5.8							Fee Schedule		5.38							Fee Schedule		5.22							Fee Schedule		5.22							Fee Schedule		28.35							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		5.22							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		
ALGY HADDOCK IGG 38141 0.5 ML SER RT	302	RC	86001	CPT				Both			52.5	23.63	5.63	47.25	5.63							Fee Schedule		7.82							Fee Schedule		8.05							Fee Schedule		7.82							Fee Schedule		7.82							Fee Schedule		47.25							Fee Schedule		8.99							Fee Schedule		7.27							Fee Schedule		7.82							Fee Schedule		8.99							Fee Schedule		7.27							Fee Schedule		
ALGY HAZEL NUT IGE 2504 0.5 ML SERUM	302	RC	86003	CPT				Both			31.5	14.18	4.64	28.35	4.64							Fee Schedule		5.8							Fee Schedule		5.38							Fee Schedule		5.22							Fee Schedule		5.22							Fee Schedule		28.35							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		5.22							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		
ALGY HELMINTHOSPORIUM HALODES  IGE 6711	302	RC	86003	CPT				Both			31.5	14.18	4.64	28.35	4.64							Fee Schedule		5.8							Fee Schedule		5.38							Fee Schedule		5.22							Fee Schedule		5.22							Fee Schedule		28.35							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		5.22							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		
ALGY HONEY BEE IGE 0.5 ML SER 2731	302	RC	86003	CPT				Both			75.6	34.02	4.64	68.04	4.64							Fee Schedule		5.8							Fee Schedule		5.38							Fee Schedule		5.22							Fee Schedule		5.22							Fee Schedule		68.04							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		5.22							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		
ALGY INSECT VENOM PNL 38038	302	RC	86003	CPT				Both			97	43.65	4.64	87.3	4.64							Fee Schedule		5.8							Fee Schedule		5.38							Fee Schedule		5.22							Fee Schedule		5.22							Fee Schedule		87.3							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		5.22							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		
ALGY JOHNSON GRASS IGE 2310 0.3ML SERUM	302	RC	86003	CPT				Both			45.15	20.32	4.64	40.64	4.64							Fee Schedule		5.8							Fee Schedule		5.38							Fee Schedule		5.22							Fee Schedule		5.22							Fee Schedule		40.64							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		5.22							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		
ALGY JUNE GRA IGE 2308 0.3ML SERUM	302	RC	86003	CPT				Both			31.5	14.18	4.64	28.35	4.64							Fee Schedule		5.8							Fee Schedule		5.38							Fee Schedule		5.22							Fee Schedule		5.22							Fee Schedule		28.35							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		5.22							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		
ALGY KIWI IGE 18862 1.0 ML SERUM RM TM	302	RC	86001	CPT				Both			31.5	14.18	5.63	28.35	5.63							Fee Schedule		7.82							Fee Schedule		8.05							Fee Schedule		7.82							Fee Schedule		7.82							Fee Schedule		28.35							Fee Schedule		8.99							Fee Schedule		7.27							Fee Schedule		7.82							Fee Schedule		8.99							Fee Schedule		7.27							Fee Schedule		
ALGY LAMB IGE 2888  1ML SERUM RM TM	302	RC	86003	CPT				Both			31.5	14.18	4.64	28.35	4.64							Fee Schedule		5.8							Fee Schedule		5.38							Fee Schedule		5.22							Fee Schedule		5.22							Fee Schedule		28.35							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		5.22							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		
ALGY LAMB'S QUARTER GOOSEFOOT IGE 2410	302	RC	86003	CPT				Both			45.15	20.32	4.64	40.64	4.64							Fee Schedule		5.8							Fee Schedule		5.38							Fee Schedule		5.22							Fee Schedule		5.22							Fee Schedule		40.64							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		5.22							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		
ALGY LATEX IGE 8927 1 ML SERUM RM TM	302	RC	86003	CPT				Both			57.75	25.99	4.64	51.98	4.64							Fee Schedule		5.8							Fee Schedule		5.38							Fee Schedule		5.22							Fee Schedule		5.22							Fee Schedule		51.98							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		5.22							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		
ALGY LEMON IGE 2708 1.0 ML SERUM	302	RC	86003	CPT				Both			31.5	14.18	4.64	28.35	4.64							Fee Schedule		5.8							Fee Schedule		5.38							Fee Schedule		5.22							Fee Schedule		5.22							Fee Schedule		28.35							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		5.22							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		
ALGY LETTUCE  IGE 2862  0.3 ML SERUM RT	302	RC	86003	CPT				Both			31.5	14.18	4.64	28.35	4.64							Fee Schedule		5.8							Fee Schedule		5.38							Fee Schedule		5.22							Fee Schedule		5.22							Fee Schedule		28.35							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		5.22							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		
ALGY LIMA BEAN IGE 30760 0.3ML SER RT	302	RC	86003	CPT				Both			36.75	16.54	4.64	33.08	4.64							Fee Schedule		5.8							Fee Schedule		5.38							Fee Schedule		5.22							Fee Schedule		5.22							Fee Schedule		33.08							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		5.22							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		
ALGY LIME IGE 2709 1.0 ML SERUM	302	RC	86003	CPT				Both			31.5	14.18	4.64	28.35	4.64							Fee Schedule		5.8							Fee Schedule		5.38							Fee Schedule		5.22							Fee Schedule		5.22							Fee Schedule		28.35							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		5.22							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		
ALGY LOBSTER IGE 2855 1 ML SERUM RM TM	302	RC	86003	CPT				Both			31.5	14.18	4.64	28.35	4.64							Fee Schedule		5.8							Fee Schedule		5.38							Fee Schedule		5.22							Fee Schedule		5.22							Fee Schedule		28.35							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		5.22							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		
ALGY LOCUST TREE IGE 2634  0.5 ML SERUM	302	RC	86003	CPT				Both			31.5	14.18	4.64	28.35	4.64							Fee Schedule		5.8							Fee Schedule		5.38							Fee Schedule		5.22							Fee Schedule		5.22							Fee Schedule		28.35							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		5.22							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		
ALGY LOMBARDY POP IGE 37336 0.3 ML SERUM	302	RC	86003	CPT				Both			90.3	40.64	4.64	81.27	4.64							Fee Schedule		5.8							Fee Schedule		5.38							Fee Schedule		5.22							Fee Schedule		5.22							Fee Schedule		81.27							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		5.22							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		
ALGY MACADAMIA  IGE 38475  0.3 ML SER RT	302	RC	86003	CPT				Both			31.5	14.18	4.64	28.35	4.64							Fee Schedule		5.8							Fee Schedule		5.38							Fee Schedule		5.22							Fee Schedule		5.22							Fee Schedule		28.35							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		5.22							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		
ALGY MALT IGE 2863 0.3ML SER RT	302	RC	86003	CPT				Both			52.5	23.63	4.64	47.25	4.64							Fee Schedule		5.8							Fee Schedule		5.38							Fee Schedule		5.22							Fee Schedule		5.22							Fee Schedule		47.25							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		5.22							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		
ALGY MANGO FRUIT (f91) IgE  23860	302	RC	86003	CPT				Both			42	18.9	4.64	37.8	4.64							Fee Schedule		5.8							Fee Schedule		5.38							Fee Schedule		5.22							Fee Schedule		5.22							Fee Schedule		37.8							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		5.22							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		
ALGY MAPLE BOX ELDER IGE 2501 ML SER	302	RC	86003	CPT				Both			31.5	14.18	4.64	28.35	4.64							Fee Schedule		5.8							Fee Schedule		5.38							Fee Schedule		5.22							Fee Schedule		5.22							Fee Schedule		28.35							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		5.22							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		
ALGY MEADOW FESCUE GRASS IGE 2304 SER	302	RC	86003	CPT				Both			45.15	20.32	4.64	40.64	4.64							Fee Schedule		5.8							Fee Schedule		5.38							Fee Schedule		5.22							Fee Schedule		5.22							Fee Schedule		40.64							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		5.22							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		
ALGY MELONS  IGE 2887  0.3 ML SERUM	302	RC	86003	CPT				Both			31.5	14.18	4.64	28.35	4.64							Fee Schedule		5.8							Fee Schedule		5.38							Fee Schedule		5.22							Fee Schedule		5.22							Fee Schedule		28.35							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		5.22							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		
ALGY MONILIFORME IGE 6696 2ML SERUM	302	RC	86003	CPT				Both			45.15	20.32	4.64	40.64	4.64							Fee Schedule		5.8							Fee Schedule		5.38							Fee Schedule		5.22							Fee Schedule		5.22							Fee Schedule		40.64							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		5.22							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		
ALGY MOSQUITO (i71) IGE  2740	302	RC	86003	CPT				Both			18	8.1	4.64	16.2	4.64							Fee Schedule		5.8							Fee Schedule		5.38							Fee Schedule		5.22							Fee Schedule		5.22							Fee Schedule		16.2							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		5.22							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		
ALGY MOUNTAIN JUNIPER IGE 2506 0.3ML SE	302	RC	86003	CPT				Both			45.15	20.32	4.64	40.64	4.64							Fee Schedule		5.8							Fee Schedule		5.38							Fee Schedule		5.22							Fee Schedule		5.22							Fee Schedule		40.64							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		5.22							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		
ALGY MOUSE URINE PRO  IGE 2658 0.5 ML SE	302	RC	86003	CPT				Both			31.5	14.18	4.64	28.35	4.64							Fee Schedule		5.8							Fee Schedule		5.38							Fee Schedule		5.22							Fee Schedule		5.22							Fee Schedule		28.35							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		5.22							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		
ALGY MOZZARELLA CHEESE IGE 14790 0.5ML S	302	RC	86003	CPT				Both			36.75	16.54	4.64	33.08	4.64							Fee Schedule		5.8							Fee Schedule		5.38							Fee Schedule		5.22							Fee Schedule		5.22							Fee Schedule		33.08							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		5.22							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		
ALGY MUCOR RACEMOSES MOLD IGE 2704 SER	302	RC	86003	CPT				Both			45.15	20.32	4.64	40.64	4.64							Fee Schedule		5.8							Fee Schedule		5.38							Fee Schedule		5.22							Fee Schedule		5.22							Fee Schedule		40.64							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		5.22							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		
ALGY MUGWORT IGE 2406 0.5 ML SERUM	302	RC	86003	CPT				Both			31.5	14.18	4.64	28.35	4.64							Fee Schedule		5.8							Fee Schedule		5.38							Fee Schedule		5.22							Fee Schedule		5.22							Fee Schedule		28.35							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		5.22							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		
ALGY MULBERRY WHITE IGE 2570 0.3 ML SER	302	RC	86003	CPT				Both			31.5	14.18	4.64	28.35	4.64							Fee Schedule		5.8							Fee Schedule		5.38							Fee Schedule		5.22							Fee Schedule		5.22							Fee Schedule		28.35							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		5.22							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		
ALGY MUSHROOM IGE 8931 1ML SERUM RM TM	302	RC	86003	CPT				Both			31.5	14.18	4.64	28.35	4.64							Fee Schedule		5.8							Fee Schedule		5.38							Fee Schedule		5.22							Fee Schedule		5.22							Fee Schedule		28.35							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		5.22							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		
ALGY MUSTARD IGE 2889 0.3ML SERUM RM TM	302	RC	86003	CPT				Both			31.5	14.18	4.64	28.35	4.64							Fee Schedule		5.8							Fee Schedule		5.38							Fee Schedule		5.22							Fee Schedule		5.22							Fee Schedule		28.35							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		5.22							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		
ALGY NAVY BEAN IGE 2815 1ML SERUM RM TM	302	RC	86001	CPT				Both			52.5	23.63	5.63	47.25	5.63							Fee Schedule		7.82							Fee Schedule		8.05							Fee Schedule		7.82							Fee Schedule		7.82							Fee Schedule		47.25							Fee Schedule		8.99							Fee Schedule		7.27							Fee Schedule		7.82							Fee Schedule		8.99							Fee Schedule		7.27							Fee Schedule		
ALGY NUTMEG 2718   1ML SERUM RM TM	302	RC	86003	CPT				Both			31.5	14.18	4.64	28.35	4.64							Fee Schedule		5.8							Fee Schedule		5.38							Fee Schedule		5.22							Fee Schedule		5.22							Fee Schedule		28.35							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		5.22							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		
ALGY OAK IGE 2507 0.3ML SERUM	302	RC	86003	CPT				Both			31.5	14.18	4.64	28.35	4.64							Fee Schedule		5.8							Fee Schedule		5.38							Fee Schedule		5.22							Fee Schedule		5.22							Fee Schedule		28.35							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		5.22							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		
ALGY OATS IGE 2807  1ML SERUM RM TM	302	RC	86003	CPT				Both			31.5	14.18	4.64	28.35	4.64							Fee Schedule		5.8							Fee Schedule		5.38							Fee Schedule		5.22							Fee Schedule		5.22							Fee Schedule		28.35							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		5.22							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		
ALGY OLIVE RUSSIAN IGE 10616 0.3ML SE	302	RC	86003	CPT				Both			36.75	16.54	4.64	33.08	4.64							Fee Schedule		5.8							Fee Schedule		5.38							Fee Schedule		5.22							Fee Schedule		5.22							Fee Schedule		33.08							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		5.22							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		
ALGY ONION IGE 2848 1ML SERUM RM TM	302	RC	86003	CPT				Both			31.5	14.18	4.64	28.35	4.64							Fee Schedule		5.8							Fee Schedule		5.38							Fee Schedule		5.22							Fee Schedule		5.22							Fee Schedule		28.35							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		5.22							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		
ALGY ORANGE IGE 2833 0.3ML SERUM RM TM	302	RC	86003	CPT				Both			31.5	14.18	4.64	28.35	4.64							Fee Schedule		5.8							Fee Schedule		5.38							Fee Schedule		5.22							Fee Schedule		5.22							Fee Schedule		28.35							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		5.22							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		
ALGY ORCHARD GRASS IGE 2303  0.3ML SERUM	302	RC	86003	CPT				Both			45.15	20.32	4.64	40.64	4.64							Fee Schedule		5.8							Fee Schedule		5.38							Fee Schedule		5.22							Fee Schedule		5.22							Fee Schedule		40.64							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		5.22							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		
ALGY OREGANO IGE 3045 0.3ML SER RT	302	RC	86003	CPT				Both			52.5	23.63	4.64	47.25	4.64							Fee Schedule		5.8							Fee Schedule		5.38							Fee Schedule		5.22							Fee Schedule		5.22							Fee Schedule		47.25							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		5.22							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		
ALGY OYSTER IGE 8932 2ML SERUM	302	RC	86003	CPT				Both			31.5	14.18	4.64	28.35	4.64							Fee Schedule		5.8							Fee Schedule		5.38							Fee Schedule		5.22							Fee Schedule		5.22							Fee Schedule		28.35							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		5.22							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		
ALGY PAPER WASP IGE 2734 0.5 ML SERUM	302	RC	86003	CPT				Both			75.6	34.02	4.64	68.04	4.64							Fee Schedule		5.8							Fee Schedule		5.38							Fee Schedule		5.22							Fee Schedule		5.22							Fee Schedule		68.04							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		5.22							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		
ALGY PAPRIKA / SWT PEPPER IGE 3047	302	RC	86003	CPT				Both			18	8.1	4.64	16.2	4.64							Fee Schedule		5.8							Fee Schedule		5.38							Fee Schedule		5.22							Fee Schedule		5.22							Fee Schedule		16.2							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		5.22							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		
ALGY PARROT FEATHERS 2662  2ML SERUM	302	RC	86003	CPT				Both			90.3	40.64	4.64	81.27	4.64							Fee Schedule		5.8							Fee Schedule		5.38							Fee Schedule		5.22							Fee Schedule		5.22							Fee Schedule		81.27							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		5.22							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		
ALGY PARSLEY  IGE 2861  0.3 ML SERUM RT	302	RC	86003	CPT				Both			31.5	14.18	4.64	28.35	4.64							Fee Schedule		5.8							Fee Schedule		5.38							Fee Schedule		5.22							Fee Schedule		5.22							Fee Schedule		28.35							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		5.22							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		
ALGY PEA IGE 2812  0.3ML SERUM RM TM	302	RC	86003	CPT				Both			31.5	14.18	4.64	28.35	4.64							Fee Schedule		5.8							Fee Schedule		5.38							Fee Schedule		5.22							Fee Schedule		5.22							Fee Schedule		28.35							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		5.22							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		
ALGY PEACH IGE 8405 2ML SERUM	302	RC	86003	CPT				Both			31.5	14.18	4.64	28.35	4.64							Fee Schedule		5.8							Fee Schedule		5.38							Fee Schedule		5.22							Fee Schedule		5.22							Fee Schedule		28.35							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		5.22							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		
ALGY PEANUT IGE 2813 0.5 ML SERUM	302	RC	86003	CPT				Both			31.5	14.18	4.64	28.35	4.64							Fee Schedule		5.8							Fee Schedule		5.38							Fee Schedule		5.22							Fee Schedule		5.22							Fee Schedule		28.35							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		5.22							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		
"ALGY PEANUT, TOT RFLX TO PNL 91747"	302	RC	86003	CPT				Both			42	18.9	4.64	37.8	4.64							Fee Schedule		5.8							Fee Schedule		5.38							Fee Schedule		5.22							Fee Schedule		5.22							Fee Schedule		37.8							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		5.22							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		
ALGY PEAR IGE 8884 1ML SERUM RM TM	302	RC	86003	CPT				Both			31.5	14.18	4.64	28.35	4.64							Fee Schedule		5.8							Fee Schedule		5.38							Fee Schedule		5.22							Fee Schedule		5.22							Fee Schedule		28.35							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		5.22							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		
ALGY PECAN HICKORY IGE 2522 0.3ML SERUM	302	RC	86003	CPT				Both			45.15	20.32	4.64	40.64	4.64							Fee Schedule		5.8							Fee Schedule		5.38							Fee Schedule		5.22							Fee Schedule		5.22							Fee Schedule		40.64							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		5.22							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		
ALGY PECAN IGE 2864 0.3 ML SERUM	302	RC	86003	CPT				Both			31.5	14.18	4.64	28.35	4.64							Fee Schedule		5.8							Fee Schedule		5.38							Fee Schedule		5.22							Fee Schedule		5.22							Fee Schedule		28.35							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		5.22							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		
ALGY PED GRP #14 7914	302	RC						Both			1.05	0.47	0.47	0.95	0.68							Fee Schedule		0.78							Fee Schedule																													0.95							Fee Schedule																																															
ALGY PENICILLIUM NOTATUM IGE 2701 SERUM	302	RC	86003	CPT				Both			45.15	20.32	4.64	40.64	4.64							Fee Schedule		5.8							Fee Schedule		5.38							Fee Schedule		5.22							Fee Schedule		5.22							Fee Schedule		40.64							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		5.22							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		
ALGY PEPPER IGE 2561  2ML SERUM	302	RC	86003	CPT				Both			90.3	40.64	4.64	81.27	4.64							Fee Schedule		5.8							Fee Schedule		5.38							Fee Schedule		5.22							Fee Schedule		5.22							Fee Schedule		81.27							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		5.22							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		
ALGY PERENNIAL RYE GRASS IGE 2305  0.3ML	302	RC	86003	CPT				Both			45.15	20.32	4.64	40.64	4.64							Fee Schedule		5.8							Fee Schedule		5.38							Fee Schedule		5.22							Fee Schedule		5.22							Fee Schedule		40.64							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		5.22							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		
ALGY PHOMA BETAE IGE 6770 2ML SERUM	302	RC	86003	CPT				Both			31.5	14.18	4.64	28.35	4.64							Fee Schedule		5.8							Fee Schedule		5.38							Fee Schedule		5.22							Fee Schedule		5.22							Fee Schedule		28.35							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		5.22							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		
ALGY PIGEON DROPPINGS IGE 2607 0.3ML SER	302	RC	86003	CPT				Both			45.15	20.32	4.64	40.64	4.64							Fee Schedule		5.8							Fee Schedule		5.38							Fee Schedule		5.22							Fee Schedule		5.22							Fee Schedule		40.64							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		5.22							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		
ALGY PIGEON FEATHERS IGE 92391 0.3ML SER	302	RC	86003	CPT				Both			76.65	34.49	4.64	68.99	4.64							Fee Schedule		5.8							Fee Schedule		5.38							Fee Schedule		5.22							Fee Schedule		5.22							Fee Schedule		68.99							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		5.22							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		
ALGY PINEAPPLE IGE 3048 2ML SERUM	302	RC	86003	CPT				Both			109.2	49.14	4.64	98.28	4.64							Fee Schedule		5.8							Fee Schedule		5.38							Fee Schedule		5.22							Fee Schedule		5.22							Fee Schedule		98.28							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		5.22							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		
ALGY PINTO BEAN IGE 37926  0.3 ML RT	302	RC	86003	CPT				Both			31.5	14.18	4.64	28.35	4.64							Fee Schedule		5.8							Fee Schedule		5.38							Fee Schedule		5.22							Fee Schedule		5.22							Fee Schedule		28.35							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		5.22							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		
ALGY PISTACHIO 2726 IGE 0.3 ML SERUM	302	RC	86003	CPT				Both			45.15	20.32	4.64	40.64	4.64							Fee Schedule		5.8							Fee Schedule		5.38							Fee Schedule		5.22							Fee Schedule		5.22							Fee Schedule		40.64							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		5.22							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		
ALGY POPPY SEED IGE 3050 0.3ML SER RT	302	RC	86003	CPT				Both			36.75	16.54	4.64	33.08	4.64							Fee Schedule		5.8							Fee Schedule		5.38							Fee Schedule		5.22							Fee Schedule		5.22							Fee Schedule		33.08							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		5.22							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		
ALGY PORK IGE 2826 0.3ML SERUM	302	RC	86003	CPT				Both			31.5	14.18	4.64	28.35	4.64							Fee Schedule		5.8							Fee Schedule		5.38							Fee Schedule		5.22							Fee Schedule		5.22							Fee Schedule		28.35							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		5.22							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		
ALGY POTATO IGE 2835 0.3ML SERUM	302	RC	86003	CPT				Both			31.5	14.18	4.64	28.35	4.64							Fee Schedule		5.8							Fee Schedule		5.38							Fee Schedule		5.22							Fee Schedule		5.22							Fee Schedule		28.35							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		5.22							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		
ALGY PRIVET IGE 3326 0.3 ML SERUM	302	RC	86003	CPT				Both			90.3	40.64	4.64	81.27	4.64							Fee Schedule		5.8							Fee Schedule		5.38							Fee Schedule		5.22							Fee Schedule		5.22							Fee Schedule		81.27							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		5.22							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		
ALGY PULLULARIA IGE 6634 0.3 ML SERUM	302	RC	86003	CPT				Both			45.15	20.32	4.64	40.64	4.64							Fee Schedule		5.8							Fee Schedule		5.38							Fee Schedule		5.22							Fee Schedule		5.22							Fee Schedule		40.64							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		5.22							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		
ALGY PUMPKIN IGE 3051 0.5 ML SERUM	302	RC	86003	CPT				Both			31.5	14.18	4.64	28.35	4.64							Fee Schedule		5.8							Fee Schedule		5.38							Fee Schedule		5.22							Fee Schedule		5.22							Fee Schedule		28.35							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		5.22							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		
ALGY RAGWEED SHO IGE 2401 0.3ML SERUM	302	RC	86003	CPT				Both			31.5	14.18	4.64	28.35	4.64							Fee Schedule		5.8							Fee Schedule		5.38							Fee Schedule		5.22							Fee Schedule		5.22							Fee Schedule		28.35							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		5.22							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		
ALGY RASPBERRY  IGE 26281  0.3 ML SERUM	302	RC	86003	CPT				Both			31.5	14.18	4.64	28.35	4.64							Fee Schedule		5.8							Fee Schedule		5.38							Fee Schedule		5.22							Fee Schedule		5.22							Fee Schedule		28.35							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		5.22							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		
"ALGY RED ANT, IGE 17043"	302	RC	86003	CPT				Both			132	59.4	4.64	118.8	4.64							Fee Schedule		5.8							Fee Schedule		5.38							Fee Schedule		5.22							Fee Schedule		5.22							Fee Schedule		118.8							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		5.22							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		
ALGY RED CEDAR IGE 30751 0.3 ML SERUM	302	RC	86003	CPT				Both			45.15	20.32	4.64	40.64	4.64							Fee Schedule		5.8							Fee Schedule		5.38							Fee Schedule		5.22							Fee Schedule		5.22							Fee Schedule		40.64							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		5.22							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		
ALGY RED MAPLE IGE 34927 0.3 ML SERUM	302	RC	86003	CPT				Both			55.65	25.04	4.64	50.09	4.64							Fee Schedule		5.8							Fee Schedule		5.38							Fee Schedule		5.22							Fee Schedule		5.22							Fee Schedule		50.09							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		5.22							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		
ALGY RED RIVER BIRCH IGE 2503 0.5ML SER	302	RC	86003	CPT				Both			45.15	20.32	4.64	40.64	4.64							Fee Schedule		5.8							Fee Schedule		5.38							Fee Schedule		5.22							Fee Schedule		5.22							Fee Schedule		40.64							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		5.22							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		
ALGY RED TOP GRASS IGE 2309  0.3ML SERUM	302	RC	86003	CPT				Both			45.15	20.32	4.64	40.64	4.64							Fee Schedule		5.8							Fee Schedule		5.38							Fee Schedule		5.22							Fee Schedule		5.22							Fee Schedule		40.64							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		5.22							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		
ALGY RICE IGE 2809 0.3ML SERUM	302	RC	86001	CPT				Both			31.5	14.18	5.63	28.35	5.63							Fee Schedule		7.82							Fee Schedule		8.05							Fee Schedule		7.82							Fee Schedule		7.82							Fee Schedule		28.35							Fee Schedule		8.99							Fee Schedule		7.27							Fee Schedule		7.82							Fee Schedule		8.99							Fee Schedule		7.27							Fee Schedule		
ALGY ROU PIGWEED IGE 2414 0.3ML SERUM	302	RC	86003	CPT				Both			31.5	14.18	4.64	28.35	4.64							Fee Schedule		5.8							Fee Schedule		5.38							Fee Schedule		5.22							Fee Schedule		5.22							Fee Schedule		28.35							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		5.22							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		
ALGY RUSSIAN THISITLE IGE 2411 0.3 ML SE	302	RC	86003	CPT				Both			31.5	14.18	4.64	28.35	4.64							Fee Schedule		5.8							Fee Schedule		5.38							Fee Schedule		5.22							Fee Schedule		5.22							Fee Schedule		28.35							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		5.22							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		
ALGY RYE IGE 2805 1 ML SERUM RM TM	302	RC	86003	CPT				Both			31.5	14.18	4.64	28.35	4.64							Fee Schedule		5.8							Fee Schedule		5.38							Fee Schedule		5.22							Fee Schedule		5.22							Fee Schedule		28.35							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		5.22							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		
ALGY SAFFLOWER IGE 17048 0.5ML SER RT	302	RC	86003	CPT				Both			52.5	23.63	4.64	47.25	4.64							Fee Schedule		5.8							Fee Schedule		5.38							Fee Schedule		5.22							Fee Schedule		5.22							Fee Schedule		47.25							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		5.22							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		
ALGY SAGE WORMWOOD IGE 2405 0.3 ML SERUM	302	RC	86003	CPT				Both			45.15	20.32	4.64	40.64	4.64							Fee Schedule		5.8							Fee Schedule		5.38							Fee Schedule		5.22							Fee Schedule		5.22							Fee Schedule		40.64							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		5.22							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		
ALGY SALAD  7917 1ML SERUM RT TM	302	RC						Both			1.05	0.47	0.47	0.95	0.68							Fee Schedule		0.78							Fee Schedule																													0.95							Fee Schedule																																															
ALGY SALMON 2841 0.3 ML SERUM	302	RC	86003	CPT				Both			31.5	14.18	4.64	28.35	4.64							Fee Schedule		5.8							Fee Schedule		5.38							Fee Schedule		5.22							Fee Schedule		5.22							Fee Schedule		28.35							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		5.22							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		
ALGY SCALLOP IGE 273 2ML SERUM	302	RC	86003	CPT				Both			31.5	14.18	4.64	28.35	4.64							Fee Schedule		5.8							Fee Schedule		5.38							Fee Schedule		5.22							Fee Schedule		5.22							Fee Schedule		28.35							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		5.22							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		
ALGY SEAFOOD  #19 7919	302	RC	86003	CPT				Both			1.05	0.47	0.47	6	4.64							Fee Schedule		5.8							Fee Schedule		5.38							Fee Schedule		5.22							Fee Schedule		5.22							Fee Schedule		0.95							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		5.22							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		
ALGY SESAME SEED 2810 1ML SERUM RM TM	302	RC	86003	CPT				Both			31.5	14.18	4.64	28.35	4.64							Fee Schedule		5.8							Fee Schedule		5.38							Fee Schedule		5.22							Fee Schedule		5.22							Fee Schedule		28.35							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		5.22							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		
ALGY SHEEP SORREL IGE 2418 0.3 ML SERUM	302	RC	86003	CPT				Both			45.15	20.32	4.64	40.64	4.64							Fee Schedule		5.8							Fee Schedule		5.38							Fee Schedule		5.22							Fee Schedule		5.22							Fee Schedule		40.64							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		5.22							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		
ALGY SHRIMP IGE 2824  0.3ML SERUM	302	RC	86003	CPT				Both			45.15	20.32	4.64	40.64	4.64							Fee Schedule		5.8							Fee Schedule		5.38							Fee Schedule		5.22							Fee Schedule		5.22							Fee Schedule		40.64							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		5.22							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		
ALGY SOLE IGE 38243 0.3ML SERUM RM TM	302	RC	86003	CPT				Both			36.75	16.54	4.64	33.08	4.64							Fee Schedule		5.8							Fee Schedule		5.38							Fee Schedule		5.22							Fee Schedule		5.22							Fee Schedule		33.08							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		5.22							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		
ALGY SOY IGE 2814 1ML SERUM RM TM	302	RC	86003	CPT				Both			31.5	14.18	4.64	28.35	4.64							Fee Schedule		5.8							Fee Schedule		5.38							Fee Schedule		5.22							Fee Schedule		5.22							Fee Schedule		28.35							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		5.22							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		
ALGY SPINACH IGG 38120 0.5 ML SER RT	302	RC	86001	CPT				Both			52.5	23.63	5.63	47.25	5.63							Fee Schedule		7.82							Fee Schedule		8.05							Fee Schedule		7.82							Fee Schedule		7.82							Fee Schedule		47.25							Fee Schedule		8.99							Fee Schedule		7.27							Fee Schedule		7.82							Fee Schedule		8.99							Fee Schedule		7.27							Fee Schedule		
ALGY SQUASH SUMMER IGE 38265 0.5ML SE	302	RC	86003	CPT				Both			36.75	16.54	4.64	33.08	4.64							Fee Schedule		5.8							Fee Schedule		5.38							Fee Schedule		5.22							Fee Schedule		5.22							Fee Schedule		33.08							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		5.22							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		
ALGY STEMPHYLIUM BOTYROSUM IGE 6799	302	RC	86003	CPT				Both			31.5	14.18	4.64	28.35	4.64							Fee Schedule		5.8							Fee Schedule		5.38							Fee Schedule		5.22							Fee Schedule		5.22							Fee Schedule		28.35							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		5.22							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		
ALGY STRAWBERRY IGE 2844 1ML SERUM RM TM	302	RC	86003	CPT				Both			31.5	14.18	4.64	28.35	4.64							Fee Schedule		5.8							Fee Schedule		5.38							Fee Schedule		5.22							Fee Schedule		5.22							Fee Schedule		28.35							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		5.22							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		
ALGY SUNFLOWER (w204) IGE 3394	302	RC	86003	CPT				Both			20	9	4.64	18	4.64							Fee Schedule		5.8							Fee Schedule		5.38							Fee Schedule		5.22							Fee Schedule		5.22							Fee Schedule		18							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		5.22							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		
ALGY SUNFLOWER SEED IGE (k84) 23864	302	RC	86003	CPT				Both			36.75	16.54	4.64	33.08	4.64							Fee Schedule		5.8							Fee Schedule		5.38							Fee Schedule		5.22							Fee Schedule		5.22							Fee Schedule		33.08							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		5.22							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		
ALGY SWEET GUM IGE 3328 0.5 ML SERUM	302	RC	86003	CPT				Both			31.5	14.18	4.64	28.35	4.64							Fee Schedule		5.8							Fee Schedule		5.38							Fee Schedule		5.22							Fee Schedule		5.22							Fee Schedule		28.35							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		5.22							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		
ALGY SWEET POTATO IGE 2555 0.5 ML SERUM	302	RC	86003	CPT				Both			31.5	14.18	4.64	28.35	4.64							Fee Schedule		5.8							Fee Schedule		5.38							Fee Schedule		5.22							Fee Schedule		5.22							Fee Schedule		28.35							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		5.22							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		
ALGY SWEET VERNAL GRASS IGE 2301  0.3ML	302	RC	86003	CPT				Both			45.15	20.32	4.64	40.64	4.64							Fee Schedule		5.8							Fee Schedule		5.38							Fee Schedule		5.22							Fee Schedule		5.22							Fee Schedule		40.64							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		5.22							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		
ALGY SWORDFISH IGE 3055 0.3ML SERUM RT	302	RC	86003	CPT				Both			36.75	16.54	4.64	33.08	4.64							Fee Schedule		5.8							Fee Schedule		5.38							Fee Schedule		5.22							Fee Schedule		5.22							Fee Schedule		33.08							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		5.22							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		
ALGY SYCAMORE IGE 2511 0.3 ML SERUM	302	RC	86003	CPT				Both			45.15	20.32	4.64	40.64	4.64							Fee Schedule		5.8							Fee Schedule		5.38							Fee Schedule		5.22							Fee Schedule		5.22							Fee Schedule		40.64							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		5.22							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		
ALGY T. VULGARIS IGE 11008  0.3ML SER RT	302	RC	86003	CPT				Both			76.65	34.49	4.64	68.99	4.64							Fee Schedule		5.8							Fee Schedule		5.38							Fee Schedule		5.22							Fee Schedule		5.22							Fee Schedule		68.99							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		5.22							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		
ALGY TARRAGON IGE 3057 0.3ML SER RT	302	RC	86003	CPT				Both			52.5	23.63	4.64	47.25	4.64							Fee Schedule		5.8							Fee Schedule		5.38							Fee Schedule		5.22							Fee Schedule		5.22							Fee Schedule		47.25							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		5.22							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		
ALGY TEA IGE 6805 0.3ML SERUM RT	302	RC	86003	CPT				Both			36.75	16.54	4.64	33.08	4.64							Fee Schedule		5.8							Fee Schedule		5.38							Fee Schedule		5.22							Fee Schedule		5.22							Fee Schedule		33.08							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		5.22							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		
ALGY TILAPIA  IGE 10724	302	RC	86003	CPT				Both			198	89.1	4.64	178.2	4.64							Fee Schedule		5.8							Fee Schedule		5.38							Fee Schedule		5.22							Fee Schedule		5.22							Fee Schedule		178.2							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		5.22							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		
ALGY TIMOTHY GRASS IGE 2306 0.3 ML SERUM	302	RC	86003	CPT				Both			45.15	20.32	4.64	40.64	4.64							Fee Schedule		5.8							Fee Schedule		5.38							Fee Schedule		5.22							Fee Schedule		5.22							Fee Schedule		40.64							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		5.22							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		
ALGY TOMATO IGE 2825 0.3ML SERUM	302	RC	86001	CPT				Both			89.25	40.16	5.63	80.33	5.63							Fee Schedule		7.82							Fee Schedule		8.05							Fee Schedule		7.82							Fee Schedule		7.82							Fee Schedule		80.33							Fee Schedule		8.99							Fee Schedule		7.27							Fee Schedule		7.82							Fee Schedule		8.99							Fee Schedule		7.27							Fee Schedule		
ALGY TROUT IgG 38142  0.5ML SERUM RT	302	RC	86001	CPT				Both			65.1	29.3	5.63	58.59	5.63							Fee Schedule		7.82							Fee Schedule		8.05							Fee Schedule		7.82							Fee Schedule		7.82							Fee Schedule		58.59							Fee Schedule		8.99							Fee Schedule		7.27							Fee Schedule		7.82							Fee Schedule		8.99							Fee Schedule		7.27							Fee Schedule		
ALGY TUNA IgE 2840 0.3 ML SERUM	302	RC	86003	CPT				Both			31.5	14.18	4.64	28.35	4.64							Fee Schedule		5.8							Fee Schedule		5.38							Fee Schedule		5.22							Fee Schedule		5.22							Fee Schedule		28.35							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		5.22							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		
ALGY TURKEY MEAT IGE 2748 0.3ML SER RT	302	RC	86003	CPT				Both			52.5	23.63	4.64	47.25	4.64							Fee Schedule		5.8							Fee Schedule		5.38							Fee Schedule		5.22							Fee Schedule		5.22							Fee Schedule		47.25							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		5.22							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		
ALGY VANILLA (f234)  IGE 3244	302	RC	86003	CPT				Both			31.5	14.18	4.64	28.35	4.64							Fee Schedule		5.8							Fee Schedule		5.38							Fee Schedule		5.22							Fee Schedule		5.22							Fee Schedule		28.35							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		5.22							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		
ALGY WALNUT IGE 3489 0.3 ML SERUM	302	RC	86003	CPT				Both			45.15	20.32	4.64	40.64	4.64							Fee Schedule		5.8							Fee Schedule		5.38							Fee Schedule		5.22							Fee Schedule		5.22							Fee Schedule		40.64							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		5.22							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		
ALGY WALNUT TREE (T10) IGE 2510	302	RC	86003	CPT				Both			42	18.9	4.64	37.8	4.64							Fee Schedule		5.8							Fee Schedule		5.38							Fee Schedule		5.22							Fee Schedule		5.22							Fee Schedule		37.8							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		5.22							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		
ALGY WATERMELON  IGE 30755  0.3 ML SERUM	302	RC	86003	CPT				Both			26.25	11.81	4.64	23.63	4.64							Fee Schedule		5.8							Fee Schedule		5.38							Fee Schedule		5.22							Fee Schedule		5.22							Fee Schedule		23.63							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		5.22							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		
ALGY WAX & STRING BEAN IGE 30530  SER RT	302	RC	86003	CPT				Both			68.25	30.71	4.64	61.43	4.64							Fee Schedule		5.8							Fee Schedule		5.38							Fee Schedule		5.22							Fee Schedule		5.22							Fee Schedule		61.43							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		5.22							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		
ALGY WHEAT BRAN IGE 39549 0.5ML SER RT	302	RC	86003	CPT				Both			52.5	23.63	4.64	47.25	4.64							Fee Schedule		5.8							Fee Schedule		5.38							Fee Schedule		5.22							Fee Schedule		5.22							Fee Schedule		47.25							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		5.22							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		
ALGY WHEAT IGE 2804 1ML SERUM RM TM	302	RC	86003	CPT				Both			31.5	14.18	4.64	28.35	4.64							Fee Schedule		5.8							Fee Schedule		5.38							Fee Schedule		5.22							Fee Schedule		5.22							Fee Schedule		28.35							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		5.22							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		
ALGY WHEY  11006 1ML SERUM	302	RC	86001	CPT				Both			89.25	40.16	5.63	80.33	5.63							Fee Schedule		7.82							Fee Schedule		8.05							Fee Schedule		7.82							Fee Schedule		7.82							Fee Schedule		80.33							Fee Schedule		8.99							Fee Schedule		7.27							Fee Schedule		7.82							Fee Schedule		8.99							Fee Schedule		7.27							Fee Schedule		
ALGY WHEY IGE 3248	302	RC	86003	CPT				Both			20	9	4.64	18	4.64							Fee Schedule		5.8							Fee Schedule		5.38							Fee Schedule		5.22							Fee Schedule		5.22							Fee Schedule		18							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		5.22							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		
ALGY WHITE ASH 2515 0.3ML SERUM	302	RC	86003	CPT				Both			45.15	20.32	4.64	40.64	4.64							Fee Schedule		5.8							Fee Schedule		5.38							Fee Schedule		5.22							Fee Schedule		5.22							Fee Schedule		40.64							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		5.22							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		
ALGY WHITE BEAN 2815	302	RC	86003	CPT				Both			18	8.1	4.64	16.2	4.64							Fee Schedule		5.8							Fee Schedule		5.38							Fee Schedule		5.22							Fee Schedule		5.22							Fee Schedule		16.2							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		5.22							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		
ALGY WHITE FACE HORNET IGE 2732 SERUM	302	RC	86003	CPT				Both			75.6	34.02	4.64	68.04	4.64							Fee Schedule		5.8							Fee Schedule		5.38							Fee Schedule		5.22							Fee Schedule		5.22							Fee Schedule		68.04							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		5.22							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		
ALGY WHITE PINE 2516 0.3 ML SERUM	302	RC	86003	CPT				Both			45.15	20.32	4.64	40.64	4.64							Fee Schedule		5.8							Fee Schedule		5.38							Fee Schedule		5.22							Fee Schedule		5.22							Fee Schedule		40.64							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		5.22							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		
ALGY WHITE POP IGE 23892 1 ML SERUM	302	RC	86003	CPT				Both			90.3	40.64	4.64	81.27	4.64							Fee Schedule		5.8							Fee Schedule		5.38							Fee Schedule		5.22							Fee Schedule		5.22							Fee Schedule		81.27							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		5.22							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		
ALGY WILLOW IGE 2512    0.3 ML SERUM	302	RC	86003	CPT				Both			31.5	14.18	4.64	28.35	4.64							Fee Schedule		5.8							Fee Schedule		5.38							Fee Schedule		5.22							Fee Schedule		5.22							Fee Schedule		28.35							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		5.22							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		
ALGY YEAST BREWERS IGG 39545 0.3 ML	302	RC	86001	CPT				Both			52.5	23.63	5.63	47.25	5.63							Fee Schedule		7.82							Fee Schedule		8.05							Fee Schedule		7.82							Fee Schedule		7.82							Fee Schedule		47.25							Fee Schedule		8.99							Fee Schedule		7.27							Fee Schedule		7.82							Fee Schedule		8.99							Fee Schedule		7.27							Fee Schedule		
ALGY YEAST IGE 2845 0.3ML SERUM RM TM	302	RC	86003	CPT				Both			31.5	14.18	4.64	28.35	4.64							Fee Schedule		5.8							Fee Schedule		5.38							Fee Schedule		5.22							Fee Schedule		5.22							Fee Schedule		28.35							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		5.22							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		
ALGY YELLOW DOCK WEED IGE 26578 0.3 ML S	302	RC	86003	CPT				Both			31.5	14.18	4.64	28.35	4.64							Fee Schedule		5.8							Fee Schedule		5.38							Fee Schedule		5.22							Fee Schedule		5.22							Fee Schedule		28.35							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		5.22							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		
ALGY YELLOW HORNET IGE 2735 0.5 ML SERUM	302	RC	86003	CPT				Both			75.6	34.02	4.64	68.04	4.64							Fee Schedule		5.8							Fee Schedule		5.38							Fee Schedule		5.22							Fee Schedule		5.22							Fee Schedule		68.04							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		5.22							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		
ALGY YELLOW JACKET IGE 2733 0.5 ML SERUM	302	RC	86003	CPT				Both			75.6	34.02	4.64	68.04	4.64							Fee Schedule		5.8							Fee Schedule		5.38							Fee Schedule		5.22							Fee Schedule		5.22							Fee Schedule		68.04							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		5.22							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		
ALGY YOGURT IGE 38339 0.5ML SER RT	302	RC	86003	CPT				Both			52.5	23.63	4.64	47.25	4.64							Fee Schedule		5.8							Fee Schedule		5.38							Fee Schedule		5.22							Fee Schedule		5.22							Fee Schedule		47.25							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		5.22							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		
ALIGNMENT TUBE	272	RC						Both			60.9	27.41	27.41	54.81	39.59							Fee Schedule		45.07							Fee Schedule																													54.81							Fee Schedule																																															
ALITRAQ 300 CAL/ 300ML PACKET UD	250	RC						Both			37.8	17.01	17.01	34.02	24.57							Fee Schedule		27.97							Fee Schedule																													34.02							Fee Schedule																																															
ALK PHOS BONE SPECIFIC 29498	301	RC	84075	CPT				Both			99.75	44.89	4.6	89.78	4.6							Fee Schedule		5.75							Fee Schedule		5.34							Fee Schedule		5.18							Fee Schedule		5.18							Fee Schedule		89.78							Fee Schedule		5.96							Fee Schedule		4.82							Fee Schedule		5.18							Fee Schedule		5.96							Fee Schedule		4.82							Fee Schedule		
ALK PHOS ISO 231 SERUM	301	RC	84080	CPT				Both			84	37.8	13.14	75.6	13.14							Fee Schedule		16.43							Fee Schedule		15.22							Fee Schedule		14.78							Fee Schedule		14.78							Fee Schedule		75.6							Fee Schedule		17							Fee Schedule		13.75							Fee Schedule		14.78							Fee Schedule		17							Fee Schedule		13.75							Fee Schedule		
ALKALINE PHOSPHATASE	301	RC	84075	CPT				Both			40.95	18.43	4.6	36.86	4.6							Fee Schedule		5.75							Fee Schedule		5.34							Fee Schedule		5.18							Fee Schedule		5.18							Fee Schedule		36.86							Fee Schedule		5.96							Fee Schedule		4.82							Fee Schedule		5.18							Fee Schedule		5.96							Fee Schedule		4.82							Fee Schedule		
ALLEGRA-D 60 MG/120MG TABLET UD	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
ALLEREST 30 MG/2MG TABLET UD	250	RC	A9270	CPT				Both			4.2	1.89	0.01	3.78	0.01							Fee Schedule		3.11							Fee Schedule																													3.78							Fee Schedule																																															
OTHER DISORDERS OF NERVOUS SYSTEM WITH CC					92	DRG		Inpatient			25170.52	11326.73	11326.73	11326.73							0		No services performed during 15 month lookback period. 				2443.81	1594.59	3293.02	1 through 10									0		No services performed during 15 month lookback period							0		No services provided during 15 month lookback period				4347.55	4347.55	4347.55	1 through 10									0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period	
ALLERGY CREAM 2% (DIPHENHYDRAMINE)	250	RC	A9270	CPT				Both			13.65	6.14	0.01	12.29	0.01							Fee Schedule		10.1							Fee Schedule																													12.29							Fee Schedule																																															
ALLEVYN DRESSING 10X20 66801751	272	RC	A6212	CPT				Both			26	11.7	8.74	23.4	8.74							Fee Schedule		19.24							Fee Schedule		14.26							Fee Schedule		10.93							Fee Schedule		13.84							Fee Schedule		23.4							Fee Schedule		15.92							Fee Schedule		12.87							Fee Schedule											15.92							Fee Schedule		12.87							Fee Schedule		
ALLEVYN DRESSING 4X4 66801067	272	RC	A6212	CPT				Both			8	3.6	3.6	15.92	8.74							Fee Schedule		5.92							Fee Schedule		14.26							Fee Schedule		10.93							Fee Schedule		13.84							Fee Schedule		7.2							Fee Schedule		15.92							Fee Schedule		12.87							Fee Schedule											15.92							Fee Schedule		12.87							Fee Schedule		
ALLEVYN DRESSING 5X5 66801068	272	RC	A6212	CPT				Both			10	4.5	4.5	15.92	8.74							Fee Schedule		7.4							Fee Schedule		14.26							Fee Schedule		10.93							Fee Schedule		13.84							Fee Schedule		9							Fee Schedule		15.92							Fee Schedule		12.87							Fee Schedule											15.92							Fee Schedule		12.87							Fee Schedule		
ALLEVYN DRESSING 6X6 66801069	272	RC	A6212	CPT				Both			14	6.3	6.3	15.92	8.74							Fee Schedule		10.36							Fee Schedule		14.26							Fee Schedule		10.93							Fee Schedule		13.84							Fee Schedule		12.6							Fee Schedule		15.92							Fee Schedule		12.87							Fee Schedule											15.92							Fee Schedule		12.87							Fee Schedule		
ALLEVYN DRESSING 8.25 X 8.25 66801070	272	RC	A6213	CPT				Both			25	11.25	11.16	22.5	11.16							Fee Schedule		18.5							Fee Schedule																													22.5							Fee Schedule																																															
ALLEVYN DRESSING HEEL 66801304	272	RC	A6213	CPT				Both			29	13.05	11.16	26.1	11.16							Fee Schedule		21.46							Fee Schedule																													26.1							Fee Schedule																																															
ALLEVYN DRESSING SACRUM LARGE 66801307	272	RC	A6213	CPT				Both			35.7	16.07	11.16	32.13	11.16							Fee Schedule		26.42							Fee Schedule																													32.13							Fee Schedule																																															
ALLEVYN DRESSING SACRUM SMALL 66801306	272	RC	A6212	CPT				Both			23.1	10.4	8.74	20.79	8.74							Fee Schedule		17.09							Fee Schedule		14.26							Fee Schedule		10.93							Fee Schedule		13.84							Fee Schedule		20.79							Fee Schedule		15.92							Fee Schedule		12.87							Fee Schedule											15.92							Fee Schedule		12.87							Fee Schedule		
ALLOGRAFT CANC. BONE CHIPS #500153	278	RC	Q4107	CPT				Both			1460.55	657.25	118.24	1314.5		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1080.81							Fee Schedule		130.95							Fee Schedule											127.14							Fee Schedule		1314.5							Fee Schedule		146.21							Fee Schedule		118.24							Fee Schedule											146.21							Fee Schedule		118.24							Fee Schedule		
ALLOPURINOL 100MG (ZYLOPRIM) TABLET	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
ALLOPURINOL 300MG (ZYLOPRIM) TABLET	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
ALPHA 1 ANTITRYP GENOTYPE 15340	310	RC	81332	CPT				Both			261	117.45	38.8	234.9	38.8							Fee Schedule		48.5							Fee Schedule		44.96							Fee Schedule		43.65							Fee Schedule		43.65							Fee Schedule		234.9							Fee Schedule		50.2							Fee Schedule		40.59							Fee Schedule											50.2							Fee Schedule		40.59							Fee Schedule		
ALPHA 1 ANTITRYP PHENOTYPE 853	301	RC	82104	CPT				Both			112.35	50.56	12.86	101.12	12.86							Fee Schedule		16.07							Fee Schedule		14.89							Fee Schedule		14.46							Fee Schedule		14.46							Fee Schedule		101.12							Fee Schedule		16.63							Fee Schedule		13.45							Fee Schedule		14.46							Fee Schedule		16.63							Fee Schedule		13.45							Fee Schedule		
ALPHA 1 ANTITRYPSIN SERUM 235	301	RC	82103	CPT				Both			133.35	60.01	11.94	120.02	11.94							Fee Schedule		14.93							Fee Schedule		13.84							Fee Schedule		13.44							Fee Schedule		13.44							Fee Schedule		120.02							Fee Schedule		15.46							Fee Schedule		12.5							Fee Schedule		13.44							Fee Schedule		15.46							Fee Schedule		12.5							Fee Schedule		
ALPHA 1 ANTITRYPSIN STOOL 14628	301	RC	82103	CPT				Both			60.9	27.41	11.94	54.81	11.94							Fee Schedule		14.93							Fee Schedule		13.84							Fee Schedule		13.44							Fee Schedule		13.44							Fee Schedule		54.81							Fee Schedule		15.46							Fee Schedule		12.5							Fee Schedule		13.44							Fee Schedule		15.46							Fee Schedule		12.5							Fee Schedule		
ALPHA MELANOCYTE STIM HORM 91898	301	RC	83520	CPT				Both			432	194.4	12.43	388.8	12.43							Fee Schedule		17.27							Fee Schedule		17.79							Fee Schedule		17.27							Fee Schedule		17.27							Fee Schedule		388.8							Fee Schedule		19.86							Fee Schedule		16.06							Fee Schedule		17.27							Fee Schedule		19.86							Fee Schedule		16.06							Fee Schedule		
ALPHA-2-MACROGLOBULIN 228   1ML SERUM	300	RC	83883	CPT				Both			273	122.85	12.09	245.7	12.09							Fee Schedule		15.11							Fee Schedule		14.01							Fee Schedule		13.6							Fee Schedule		13.6							Fee Schedule		245.7							Fee Schedule		15.64							Fee Schedule		12.65							Fee Schedule		13.6							Fee Schedule		15.64							Fee Schedule		12.65							Fee Schedule		
ALPHA-GAL PANEL 10555 - ALGY LAMB	302	RC	86003	CPT				Both			30.75	13.84	4.64	27.68	4.64							Fee Schedule		5.8							Fee Schedule		5.38							Fee Schedule		5.22							Fee Schedule		5.22							Fee Schedule		27.68							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		5.22							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		
ALPRAZOLAM 0.25 MG (XANAX) ODT TABLET	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
ALPRAZOLAM 0.5 MG (XANAX) ODT TABLET	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
ALPRAZOLAM 0.5 MG (XANAX) TABLET	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
ALTERNAGEL SUSP 15ML UD	250	RC	A9270	CPT				Both			4.2	1.89	0.01	3.78	0.01							Fee Schedule		3.11							Fee Schedule																													3.78							Fee Schedule																																															
ALTIS KIT 519650	278	RC	C1771	CPT				Both			6523.65	2935.64	2935.64	5871.29		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	4827.5							Fee Schedule																													5871.29							Fee Schedule																																															
ALUMINUM 6021 ROYAL BLUE TUBE	301	RC	82108	CPT				Both			113.4	51.03	22.65	102.06	22.65							Fee Schedule		28.31							Fee Schedule		26.24							Fee Schedule		25.48							Fee Schedule		25.48							Fee Schedule		102.06							Fee Schedule		29.3							Fee Schedule		23.7							Fee Schedule		25.48							Fee Schedule		29.3							Fee Schedule		23.7							Fee Schedule		
ALUMINUM HYDROXIDE 320 MG/5ML SUSP UD	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
ALUPENT INHALER	636	RC	J3535	CPT				Both			65.1	29.3	29.3	58.59		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	48.17							Fee Schedule																													58.59							Fee Schedule																																															
AMANTADINE 100 MG CAPSULE	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
AMANTADINE 50 MG/5ML SYRUP	250	RC	A9270	CPT				Both			5.55	2.5	0.01	5	0.01							Fee Schedule		4.11							Fee Schedule																													5							Fee Schedule																																															
AMANTADINE 5257 2ML SERUM SYMMETREL	301	RC	80299	CPT				Both			165.9	74.66	13.42	149.31	13.42							Fee Schedule		18.64							Fee Schedule		19.2							Fee Schedule		18.64							Fee Schedule		18.64							Fee Schedule		149.31							Fee Schedule		21.44							Fee Schedule		17.34							Fee Schedule		18.64							Fee Schedule		21.44							Fee Schedule		17.34							Fee Schedule		
AMB BP MONITOR RECORD ONLY	278	RC	93786	CPT				Both			1050	472.5	4.41	945		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	777							Fee Schedule											4.41							Fee Schedule											945							Fee Schedule																																															
AMB BP MONITOR SCAN ANAL W REPORT	278	RC	93788	CPT				Both			1050	472.5	135.3	945		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	777							Fee Schedule											135.3							Fee Schedule											945							Fee Schedule																																															
AMBIENT KNEE WAND ASHA4830-01	272	RC						Both			405	182.25	182.25	364.5	263.25							Fee Schedule		299.7							Fee Schedule																													364.5							Fee Schedule																																															
AMBIENT SHOULDER WAND ASHA4250-01	272	RC						Both			435	195.75	195.75	391.5	282.75							Fee Schedule		321.9							Fee Schedule																													391.5							Fee Schedule																																															
AMBU BAG ADULT CPRM4416	271	RC						Both			38	17.1	17.1	34.2	24.7							Fee Schedule		28.12							Fee Schedule																													34.2							Fee Schedule																																															
AMBU BAG CHILD MEDLINE CPRM2216FM	271	RC						Both			54	24.3	24.3	48.6	35.1							Fee Schedule		39.96							Fee Schedule																													48.6							Fee Schedule																																															
AMBU BAG INFANT 544211000	271	RC						Both			54	24.3	24.3	48.6	35.1							Fee Schedule		39.96							Fee Schedule																													48.6							Fee Schedule																																															
AMBU BAG INFANT PORTEX	271	RC						Both			85.05	38.27	38.27	76.55	55.28							Fee Schedule		62.94							Fee Schedule																													76.55							Fee Schedule																																															
AMBU BAG NEWBORN 10-55284  ( SENECA )	271	RC						Both			137.55	61.9	61.9	123.8	89.41							Fee Schedule		101.79							Fee Schedule																													123.8							Fee Schedule																																															
AMBU BAG PED 5367 (SENECA)	271	RC						Both			69.3	31.19	31.19	62.37	45.05							Fee Schedule		51.28							Fee Schedule																													62.37							Fee Schedule																																															
AMERICAINE 20% ANESTHETIC SPRAY- 2 OZ	250	RC	A9270	CPT				Both			14.7	6.62	0.01	13.23	0.01							Fee Schedule		10.88							Fee Schedule																													13.23							Fee Schedule																																															
AMERICAINE LUBRICANT 20%- 2OZ	250	RC	A9270	CPT				Both			57.75	25.99	0.01	51.98	0.01							Fee Schedule		42.74							Fee Schedule																													51.98							Fee Schedule																																															
AMERICAINE OTIC	250	RC	A9270	CPT				Both			43.05	19.37	0.01	38.75	0.01							Fee Schedule		31.86							Fee Schedule																													38.75							Fee Schedule																																															
AMIKACIN 500MG/100ML  IVPB	250	RC	J0278	CPT				Both			54.6	24.57	0.57	49.14	1.28							Fee Schedule		40.4							Fee Schedule		0.63							Fee Schedule											0.61							Fee Schedule		49.14							Fee Schedule		0.71							Fee Schedule		0.57							Fee Schedule											0.71							Fee Schedule		0.57							Fee Schedule		
AMIKACIN PEAK SERUM RED	300	RC	80150	CPT				Both			84	37.8	13.4	75.6	13.4							Fee Schedule		16.75							Fee Schedule		15.53							Fee Schedule		15.08							Fee Schedule		15.08							Fee Schedule		75.6							Fee Schedule		17.34							Fee Schedule		14.02							Fee Schedule		15.08							Fee Schedule		17.34							Fee Schedule		14.02							Fee Schedule		
AMIKACIN RANDOM	300	RC	80150	CPT				Both			84	37.8	13.4	75.6	13.4							Fee Schedule		16.75							Fee Schedule		15.53							Fee Schedule		15.08							Fee Schedule		15.08							Fee Schedule		75.6							Fee Schedule		17.34							Fee Schedule		14.02							Fee Schedule		15.08							Fee Schedule		17.34							Fee Schedule		14.02							Fee Schedule		
AMIKACIN SULFATE 250MG/ML-2ML INJ	250	RC	J0278	CPT				Both			46.2	20.79	0.57	41.58	1.28							Fee Schedule		34.19							Fee Schedule		0.63							Fee Schedule											0.61							Fee Schedule		41.58							Fee Schedule		0.71							Fee Schedule		0.57							Fee Schedule											0.71							Fee Schedule		0.57							Fee Schedule		
AMIKACIN TROUGH SERUM RED	300	RC	80150	CPT				Both			84	37.8	13.4	75.6	13.4							Fee Schedule		16.75							Fee Schedule		15.53							Fee Schedule		15.08							Fee Schedule		15.08							Fee Schedule		75.6							Fee Schedule		17.34							Fee Schedule		14.02							Fee Schedule		15.08							Fee Schedule		17.34							Fee Schedule		14.02							Fee Schedule		
AMINO ACID ANALYSIS PLASMA 767	301	RC	82139	CPT				Both			321.3	144.59	15	289.17	15							Fee Schedule		18.74							Fee Schedule		17.38							Fee Schedule		16.87							Fee Schedule		16.87							Fee Schedule		289.17							Fee Schedule		19.4							Fee Schedule		15.69							Fee Schedule		16.87							Fee Schedule		19.4							Fee Schedule		15.69							Fee Schedule		
AMINO ACID SCR PL 238	301	RC	82131	CPT				Both			100.8	45.36	16.55	90.72	16.55							Fee Schedule		22.98							Fee Schedule		23.67							Fee Schedule		22.98							Fee Schedule		22.98							Fee Schedule		90.72							Fee Schedule		26.43							Fee Schedule		21.37							Fee Schedule		22.98							Fee Schedule		26.43							Fee Schedule		21.37							Fee Schedule		
AMINO ACID URINE FZ  36183	301	RC	82139	CPT				Both			321.3	144.59	15	289.17	15							Fee Schedule		18.74							Fee Schedule		17.38							Fee Schedule		16.87							Fee Schedule		16.87							Fee Schedule		289.17							Fee Schedule		19.4							Fee Schedule		15.69							Fee Schedule		16.87							Fee Schedule		19.4							Fee Schedule		15.69							Fee Schedule		
AMINOCAPROIC ACID 250MG/ML-20ML VIAL	250	RC	J0281	CPT				Both			33.87	15.24	1.74	30.48	22.02							Fee Schedule		25.06							Fee Schedule		1.92							Fee Schedule											1.87							Fee Schedule		30.48							Fee Schedule		2.15							Fee Schedule		1.74							Fee Schedule											2.15							Fee Schedule		1.74							Fee Schedule		
AMINOCAPROIC ACID 5000 MG/250 ML NS	250	RC	J0281	CPT				Both			37.8	17.01	1.74	34.02	24.57							Fee Schedule		27.97							Fee Schedule		1.92							Fee Schedule											1.87							Fee Schedule		34.02							Fee Schedule		2.15							Fee Schedule		1.74							Fee Schedule											2.15							Fee Schedule		1.74							Fee Schedule		
AMINOCAPROIC ACID INJ 1000MG/50ML NS	250	RC	J0281	CPT				Both			32.55	14.65	1.74	29.3	21.16							Fee Schedule		24.09							Fee Schedule		1.92							Fee Schedule											1.87							Fee Schedule		29.3							Fee Schedule		2.15							Fee Schedule		1.74							Fee Schedule											2.15							Fee Schedule		1.74							Fee Schedule		
AMINOLEVULINI ACID 219  ALA URINE 24HR	301	RC	82135	CPT				Both			123.9	55.76	14.62	111.51	14.62							Fee Schedule		18.28							Fee Schedule		16.94							Fee Schedule		16.45							Fee Schedule		16.45							Fee Schedule		111.51							Fee Schedule		18.92							Fee Schedule		15.3							Fee Schedule		16.45							Fee Schedule		18.92							Fee Schedule		15.3							Fee Schedule		
AMINOPHYLLINE 100 MG TABLET	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
AMINOPHYLLINE 250 MG VIAL-10ML	636	RC	J0280	CPT				Both			26.25	11.81	1.42	23.63		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	19.43							Fee Schedule		11.49							Fee Schedule		1.42							Fee Schedule		11.16							Fee Schedule		23.63							Fee Schedule		12.83							Fee Schedule		10.38							Fee Schedule											12.83							Fee Schedule		10.38							Fee Schedule		
AMINOPHYLLINE 250 MG/10ML VIAL	636	RC	J0280	CPT				Both			11.55	5.2	1.42	12.83		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	8.55							Fee Schedule		11.49							Fee Schedule		1.42							Fee Schedule		11.16							Fee Schedule		10.4							Fee Schedule		12.83							Fee Schedule		10.38							Fee Schedule											12.83							Fee Schedule		10.38							Fee Schedule		
AMINOPHYLLINE STANDARD DRIP	636	RC	J0280	CPT				Both			39.9	17.96	1.42	35.91		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	29.53							Fee Schedule		11.49							Fee Schedule		1.42							Fee Schedule		11.16							Fee Schedule		35.91							Fee Schedule		12.83							Fee Schedule		10.38							Fee Schedule											12.83							Fee Schedule		10.38							Fee Schedule		
AMINOSYN 2.75/DEXTROSE 10%-1000 ML	250	RC						Both			126	56.7	56.7	113.4	81.9							Fee Schedule		93.24							Fee Schedule																													113.4							Fee Schedule																																															
AMIODARONE 150 MG/100 ML PREMIX (NEXTERO	636	RC	J0283	CPT				Both			131.25	59.06	2.19	118.13		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	97.13							Fee Schedule		2.43							Fee Schedule											2.36							Fee Schedule		118.13							Fee Schedule		2.71							Fee Schedule		2.19							Fee Schedule											2.71							Fee Schedule		2.19							Fee Schedule		
AMIODARONE 150 MG/3ML PF SYRINGE	636	RC	J0282	CPT				Both			37.8	17.01	0.37	34.02		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	27.97							Fee Schedule		0.41							Fee Schedule											0.4							Fee Schedule		34.02							Fee Schedule		0.46							Fee Schedule		0.37							Fee Schedule											0.46							Fee Schedule		0.37							Fee Schedule		
AMIODARONE 150 MG/3ML VIAL	636	RC	J0282	CPT				Both			12.6	5.67	0.37	11.34		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	9.32							Fee Schedule		0.41							Fee Schedule											0.4							Fee Schedule		11.34							Fee Schedule		0.46							Fee Schedule		0.37							Fee Schedule											0.46							Fee Schedule		0.37							Fee Schedule		
AMIODARONE 360 MG/200 ML PREMIX (NEXTERO	636	RC	J0283	CPT				Both			174.3	78.44	2.19	156.87		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	128.98							Fee Schedule		2.43							Fee Schedule											2.36							Fee Schedule		156.87							Fee Schedule		2.71							Fee Schedule		2.19							Fee Schedule											2.71							Fee Schedule		2.19							Fee Schedule		
AMIODARONE 36721 SERUM	301	RC	80299	CPT				Both			165.9	74.66	13.42	149.31	13.42							Fee Schedule		18.64							Fee Schedule		19.2							Fee Schedule		18.64							Fee Schedule		18.64							Fee Schedule		149.31							Fee Schedule		21.44							Fee Schedule		17.34							Fee Schedule		18.64							Fee Schedule		21.44							Fee Schedule		17.34							Fee Schedule		
AMIODARONE 900 MG/500 ML  IVPB	636	RC	J0282	CPT				Both			258.3	116.24	0.37	232.47		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	191.14							Fee Schedule		0.41							Fee Schedule											0.4							Fee Schedule		232.47							Fee Schedule		0.46							Fee Schedule		0.37							Fee Schedule											0.46							Fee Schedule		0.37							Fee Schedule		
AMITIZA (LUBIPROSTONE) 24 MCG CAPSULE	250	RC	A9270	CPT				Both			23.1	10.4	0.01	20.79	0.01							Fee Schedule		17.09							Fee Schedule																													20.79							Fee Schedule																																															
AMITIZA (LUBIPROSTONE) 8 MCG CAPSULE	250	RC	A9270	CPT				Both			23.1	10.4	0.01	20.79	0.01							Fee Schedule		17.09							Fee Schedule																													20.79							Fee Schedule																																															
AMITRIPTYLINE 10MG (ELAVIL) TABLET	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
AMITRIPTYLINE 25MG (ELAVIL) TABLET	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
AMITRIPTYLINE 423 SERUM ELAVIL	301	RC	80307	CPT				Both			82.95	37.33	37.33	74.66	51.72							Fee Schedule		64.65							Fee Schedule		64							Fee Schedule		62.14							Fee Schedule		62.14							Fee Schedule		74.66							Fee Schedule		71.46							Fee Schedule		57.79							Fee Schedule		62.14							Fee Schedule		71.46							Fee Schedule		57.79							Fee Schedule		
AMITRIPTYLINE 50MG ( ELAVIL) TABLET	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
AMLODIPINE 10 MG (NORVASC) TABLET	250	RC	A9270	CPT				Both			6.77	3.05	0.01	6.09	0.01							Fee Schedule		5.01							Fee Schedule																													6.09							Fee Schedule																																															
AMLODIPINE 2.5 MG (NORVASC) TABLET	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
AMLODIPINE 5 MG (NORVASC) TABLET	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
AMLODIPINE/ BENAZEPRIL 5/10MG (LOTREL)	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
AMLODIPINE/ BENAZEPRIL 5/20MG (LOTREL)	250	RC	A9270	CPT				Both			7.35	3.31	0.01	6.62	0.01							Fee Schedule		5.44							Fee Schedule																													6.62							Fee Schedule																																															
AMMONIA BLOOD GREEN TOP ON ICE	301	RC	82140	CPT				Both			102.9	46.31	12.95	92.61	12.95							Fee Schedule		16.19							Fee Schedule		15.01							Fee Schedule		14.57							Fee Schedule		14.57							Fee Schedule		92.61							Fee Schedule		16.76							Fee Schedule		13.55							Fee Schedule		14.57							Fee Schedule		16.76							Fee Schedule		13.55							Fee Schedule		
AMMONIA INHALANT	250	RC						Both			6.3	2.84	2.84	5.67	4.1							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
AMNI-HOOK #DYNJ04230	272	RC						Both			2	0.9	0.9	1.8	1.3							Fee Schedule		1.48							Fee Schedule																													1.8							Fee Schedule																																															
AMNIOCENTESIS TRAY	272	RC						Both			48.3	21.74	21.74	43.47	31.4							Fee Schedule		35.74							Fee Schedule																													43.47							Fee Schedule																																															
AMOX/POT CLAV 400MG/57MG/5ML SUSP-100ML	250	RC	A9270	CPT				Both			206.79	93.06	0.01	186.11	0.01							Fee Schedule		153.02							Fee Schedule																													186.11							Fee Schedule																																															
AMOXICILIN/POT CLAV 875 MG TABLET UD	250	RC	A9270	CPT				Both			16.28	7.33	0.01	14.65	0.01							Fee Schedule		12.05							Fee Schedule																													14.65							Fee Schedule																																															
AMOXICILLIN  125MG/5ML SUSP-100 ML	250	RC	A9270	CPT				Both			11.55	5.2	0.01	10.4	0.01							Fee Schedule		8.55							Fee Schedule																													10.4							Fee Schedule																																															
AMOXICILLIN  250MG/5ML SUSP-100 ML	250	RC	A9270	CPT				Both			18.9	8.51	0.01	17.01	0.01							Fee Schedule		13.99							Fee Schedule																													17.01							Fee Schedule																																															
AMOXICILLIN 250MG CAPSULE	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
AMOXICILLIN 500 MG CAPSULE	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
AMOXICILLIN 500MG CAPSULE	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
AMOXICILLIN/ POT CLAV  600 MG/5ML - 75ML	250	RC	A9270	CPT				Both			162.75	73.24	0.01	146.48	0.01							Fee Schedule		120.44							Fee Schedule																													146.48							Fee Schedule																																															
AMOXICILLIN/CLAVULANIC 250/125MG TABLET	250	RC	A9270	CPT				Both			18.9	8.51	0.01	17.01	0.01							Fee Schedule		13.99							Fee Schedule																													17.01							Fee Schedule																																															
AMOXICILLIN/CLAVULANIC 500/125MG TABLET	250	RC	A9270	CPT				Both			11.55	5.2	0.01	10.4	0.01							Fee Schedule		8.55							Fee Schedule																													10.4							Fee Schedule																																															
AMOXICILLIN/POT CLAV 400 MG/5ML SUS 50ML	250	RC	A9270	CPT				Both			216.3	97.34	0.01	194.67	0.01							Fee Schedule		160.06							Fee Schedule																													194.67							Fee Schedule																																															
AMOXIL 125 SUSP UD (AMOXICILLIN)	250	RC	A9270	CPT				Both			3.15	1.42	0.01	2.84	0.01							Fee Schedule		2.33							Fee Schedule																													2.84							Fee Schedule																																															
"AMPHETAMINES, QUAN URN 90262"	300	RC	80325	CPT				Both			150	67.5	0.01	135	0.01							Fee Schedule									Other	No Additional Reimbursement 																												135							Fee Schedule																																															
AMPHOTERICIN B  50MG VIAL	636	RC	J0285	CPT				Both			647.85	291.53	38.98	583.07		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	479.41							Fee Schedule		43.18							Fee Schedule		119.97							Fee Schedule		41.92							Fee Schedule		583.07							Fee Schedule		48.21							Fee Schedule		38.98							Fee Schedule											48.21							Fee Schedule		38.98							Fee Schedule		
AMPHOTERICIN B LIPOSOME 50MG INJ	636	RC	J0289	CPT				Both			917.1	412.7	19.27	825.39		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	22.81							Fee Schedule		21.34							Fee Schedule											20.72							Fee Schedule		825.39							Fee Schedule		23.83							Fee Schedule		19.27							Fee Schedule											23.83							Fee Schedule		19.27							Fee Schedule		
AMPICIL /SULBACT  3GM/NS 100ML IVPB	636	RC	J0295	CPT				Both			82.95	37.33	1.35	74.66		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	61.38							Fee Schedule		1.49							Fee Schedule		8.79							Fee Schedule		1.45							Fee Schedule		74.66							Fee Schedule		1.67							Fee Schedule		1.35							Fee Schedule											1.67							Fee Schedule		1.35							Fee Schedule		
AMPICIL/SULBACT  1.5GM/NS 100ML IVPB	636	RC	J0295	CPT				Both			59.85	26.93	1.35	53.87		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	44.29							Fee Schedule		1.49							Fee Schedule		8.79							Fee Schedule		1.45							Fee Schedule		53.87							Fee Schedule		1.67							Fee Schedule		1.35							Fee Schedule											1.67							Fee Schedule		1.35							Fee Schedule		
AMPICILL/ SULBAC 1.5GM(SOLUSET/SYR PUMP)	636	RC	J0295	CPT				Both			24.15	10.87	1.35	21.74		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	17.87							Fee Schedule		1.49							Fee Schedule		8.79							Fee Schedule		1.45							Fee Schedule		21.74							Fee Schedule		1.67							Fee Schedule		1.35							Fee Schedule											1.67							Fee Schedule		1.35							Fee Schedule		
AMPICILLIN 1 GM VIAL	636	RC	J0290	CPT				Both			27.3	12.29	0.57	24.57		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	20.2							Fee Schedule		0.63							Fee Schedule		2.48							Fee Schedule		0.61							Fee Schedule		24.57							Fee Schedule		0.71							Fee Schedule		0.57							Fee Schedule											0.71							Fee Schedule		0.57							Fee Schedule		
AMPICILLIN 1 GM VIAL (SOLUSET/SYR PUMP)	636	RC	J0290	CPT				Both			27.3	12.29	0.57	24.57		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	20.2							Fee Schedule		0.63							Fee Schedule		2.48							Fee Schedule		0.61							Fee Schedule		24.57							Fee Schedule		0.71							Fee Schedule		0.57							Fee Schedule											0.71							Fee Schedule		0.57							Fee Schedule		
AMPICILLIN 1 GM/ NS 100 ML IVPB	636	RC	J0290	CPT				Both			47.25	21.26	0.57	42.53		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	34.97							Fee Schedule		0.63							Fee Schedule		2.48							Fee Schedule		0.61							Fee Schedule		42.53							Fee Schedule		0.71							Fee Schedule		0.57							Fee Schedule											0.71							Fee Schedule		0.57							Fee Schedule		
AMPICILLIN 125 MG/5ML ORAL SUSP-100ML	250	RC	A9270	CPT				Both			30.05	13.52	0.01	27.05	0.01							Fee Schedule		22.24							Fee Schedule																													27.05							Fee Schedule																																															
AMPICILLIN 2 GM /NS 100 ML IVPB	636	RC	J0290	CPT				Both			71.4	32.13	0.57	64.26		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	52.84							Fee Schedule		0.63							Fee Schedule		2.48							Fee Schedule		0.61							Fee Schedule		64.26							Fee Schedule		0.71							Fee Schedule		0.57							Fee Schedule											0.71							Fee Schedule		0.57							Fee Schedule		
AMPICILLIN 2 GM VIAL	636	RC	J0290	CPT				Both			52.5	23.63	0.57	47.25		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	38.85							Fee Schedule		0.63							Fee Schedule		2.48							Fee Schedule		0.61							Fee Schedule		47.25							Fee Schedule		0.71							Fee Schedule		0.57							Fee Schedule											0.71							Fee Schedule		0.57							Fee Schedule		
AMPICILLIN 250 MG CAPSULE	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
AMPICILLIN 500 MG VIAL	636	RC	J0290	CPT				Both			13.65	6.14	0.57	12.29		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	10.1							Fee Schedule		0.63							Fee Schedule		2.48							Fee Schedule		0.61							Fee Schedule		12.29							Fee Schedule		0.71							Fee Schedule		0.57							Fee Schedule											0.71							Fee Schedule		0.57							Fee Schedule		
AMPICILLIN 500 MG VIAL (SOLUSET/SYR PUMP	636	RC	J0290	CPT				Both			13.65	6.14	0.57	12.29		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	10.1							Fee Schedule		0.63							Fee Schedule		2.48							Fee Schedule		0.61							Fee Schedule		12.29							Fee Schedule		0.71							Fee Schedule		0.57							Fee Schedule											0.71							Fee Schedule		0.57							Fee Schedule		
AMPICILLIN/SULBACTAM 1.5 GM (UNASYN)VIAL	636	RC	J0295	CPT				Both			24.15	10.87	1.35	21.74		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	17.87							Fee Schedule		1.49							Fee Schedule		8.79							Fee Schedule		1.45							Fee Schedule		21.74							Fee Schedule		1.67							Fee Schedule		1.35							Fee Schedule											1.67							Fee Schedule		1.35							Fee Schedule		
AMPICILLIN/SULBACTAM 3 GM (UNASYN) VIAL	636	RC	J0295	CPT				Both			46.2	20.79	1.35	41.58		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	34.19							Fee Schedule		1.49							Fee Schedule		8.79							Fee Schedule		1.45							Fee Schedule		41.58							Fee Schedule		1.67							Fee Schedule		1.35							Fee Schedule											1.67							Fee Schedule		1.35							Fee Schedule		
AMPLATZ GUIDEWIRE STRAIGHT #M0066401081	272	RC						Both			84	37.8	37.8	75.6	54.6							Fee Schedule		62.16							Fee Schedule																													75.6							Fee Schedule																																															
AMPLATZ RENAL DILATOR SET  #075000	272	RC	C1726	CPT				Both			737	331.65	135.94	663.3	135.94							Fee Schedule		545.38							Fee Schedule																													663.3							Fee Schedule																																															
AMPLATZ STIFF GUIDEWIRE #M001465261	272	RC	C1769	CPT				Both			183	82.35	82.35	164.7	154.26							Fee Schedule		135.42							Fee Schedule																													164.7							Fee Schedule																																															
AMPLATZ SUPERSTIFF GUIDEWIRE #M001465021	272	RC	C1769	CPT				Both			183	82.35	82.35	164.7	154.26							Fee Schedule		135.42							Fee Schedule																													164.7							Fee Schedule																																															
AMPLATZ SUPERSTIFF GUIDEWIRE #M001465251	272	RC	C1769	CPT				Both			183	82.35	82.35	164.7	154.26							Fee Schedule		135.42							Fee Schedule																													164.7							Fee Schedule																																															
AMPLATZ SUPERSTIFF GUIDEWIRE #M00550090	272	RC	C1769	CPT				Both			434	195.3	154.26	390.6	154.26							Fee Schedule		321.16							Fee Schedule																													390.6							Fee Schedule																																															
AMPOTERICIN B LIPID COMPLEX:100 MG/20ML	636	RC	J0287	CPT				Both			824.25	370.91	370.91	741.83		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	609.95							Fee Schedule																													741.83							Fee Schedule																																															
OTHER DISORDERS OF NERVOUS SYSTEM WITHOUT CC/MCC					93	DRG		Inpatient			20150.1	9067.55	9067.55	9067.55							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period	
SEIZURES WITH MCC					100	DRG		Inpatient			38167.45	17175.35	17175.35	17175.35							0		No services performed during 15 month lookback period. 				5412.07	5412.07	5412.07	1 through 10									0		No services performed during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period	
SEIZURES WITHOUT MCC					101	DRG		Inpatient			23138.38	10412.27	10412.27	10412.27							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period				2429.4	2429.4	2429.4	1 through 10									0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period	
HEADACHES WITHOUT MCC					103	DRG		Inpatient			19281.64	8676.74	8676.74	8676.74							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period				2437.07	2437.07	2437.07	1 through 10									0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period	
"EAR, NOSE, MOUTH AND THROAT MALIGNANCY WITH MCC"					146	DRG		Inpatient			28278.35	12725.26	12725.26	12725.26							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period	
AMS ELEVATE ANTERIOR  720093-01( AMS	278	RC	C1781	CPT				Both			6447	2901.15	2901.15	5802.3		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	4770.78							Fee Schedule																													5802.3							Fee Schedule																																															
AMS700LGX MS PUMP  72404252-10	278	RC	C1813	CPT				Both			45270	20371.5	20371.5	40743		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	33499.8							Fee Schedule																													40743							Fee Schedule																																															
AMYL NITRATE INHALAN	250	RC						Both			21	9.45	9.45	18.9	13.65							Fee Schedule		15.54							Fee Schedule																													18.9							Fee Schedule																																															
AMYLASE	301	RC	82150	CPT				Both			124.95	56.23	5.76	112.46	5.76							Fee Schedule		7.2							Fee Schedule		6.67							Fee Schedule		6.48							Fee Schedule		6.48							Fee Schedule		112.46							Fee Schedule		7.45							Fee Schedule		6.03							Fee Schedule		6.48							Fee Schedule		7.45							Fee Schedule		6.03							Fee Schedule		
AMYLASE ISO 36187 SERUM 2ML	301	RC	82150	CPT				Both			119.7	53.87	5.76	107.73	5.76							Fee Schedule		7.2							Fee Schedule		6.67							Fee Schedule		6.48							Fee Schedule		6.48							Fee Schedule		107.73							Fee Schedule		7.45							Fee Schedule		6.03							Fee Schedule		6.48							Fee Schedule		7.45							Fee Schedule		6.03							Fee Schedule		
AMYLASE PERITONEAL FLUID 17414  2ML REF	301	RC	82150	CPT				Both			85.05	38.27	5.76	76.55	5.76							Fee Schedule		7.2							Fee Schedule		6.67							Fee Schedule		6.48							Fee Schedule		6.48							Fee Schedule		76.55							Fee Schedule		7.45							Fee Schedule		6.03							Fee Schedule		6.48							Fee Schedule		7.45							Fee Schedule		6.03							Fee Schedule		
AMYLASE PLEURAL FLUID 17415 2ML FROZEN	301	RC	82150	CPT				Both			85.05	38.27	5.76	76.55	5.76							Fee Schedule		7.2							Fee Schedule		6.67							Fee Schedule		6.48							Fee Schedule		6.48							Fee Schedule		76.55							Fee Schedule		7.45							Fee Schedule		6.03							Fee Schedule		6.48							Fee Schedule		7.45							Fee Schedule		6.03							Fee Schedule		
AMYLASE URINE 8464	301	RC	82150	CPT				Both			113.4	51.03	5.76	102.06	5.76							Fee Schedule		7.2							Fee Schedule		6.67							Fee Schedule		6.48							Fee Schedule		6.48							Fee Schedule		102.06							Fee Schedule		7.45							Fee Schedule		6.03							Fee Schedule		6.48							Fee Schedule		7.45							Fee Schedule		6.03							Fee Schedule		
ANA 249 SERUM LE PREP	302	RC	86038	CPT				Both			140.7	63.32	10.74	126.63	10.74							Fee Schedule		13.43							Fee Schedule		12.45							Fee Schedule		12.09							Fee Schedule		12.09							Fee Schedule		126.63							Fee Schedule		13.9							Fee Schedule		11.24							Fee Schedule		12.09							Fee Schedule		13.9							Fee Schedule		11.24							Fee Schedule		
ANAEROBIC CULT IDENT 4471	306	RC	87076	CPT				Both			60.9	27.41	7.18	54.81	7.18							Fee Schedule		8.97							Fee Schedule		8.32							Fee Schedule		8.08							Fee Schedule		8.08							Fee Schedule		54.81							Fee Schedule		9.29							Fee Schedule		7.51							Fee Schedule		8.08							Fee Schedule		9.29							Fee Schedule		7.51							Fee Schedule		
ANAEROBIC CULT IDENT 4471	306	RC	87076	CPT				Both			60.9	27.41	7.18	54.81	7.18							Fee Schedule		8.97							Fee Schedule		8.32							Fee Schedule		8.08							Fee Schedule		8.08							Fee Schedule		54.81							Fee Schedule		9.29							Fee Schedule		7.51							Fee Schedule		8.08							Fee Schedule		9.29							Fee Schedule		7.51							Fee Schedule		
ANAEROBIC CULT ISOLA	306	RC	87075	CPT				Both			157	70.65	8.42	141.3	8.42							Fee Schedule		10.52							Fee Schedule		9.75							Fee Schedule		9.47							Fee Schedule		9.47							Fee Schedule		141.3							Fee Schedule		10.89							Fee Schedule		8.81							Fee Schedule		9.47							Fee Schedule		10.89							Fee Schedule		8.81							Fee Schedule		
DYSEQUILIBRIUM					149	DRG		Inpatient			26065.85	11729.63	11729.63	11729.63							0		No services performed during 15 month lookback period. 				4283.43	3040.85	5526	1 through 10									0		No services performed during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period	
OTITIS MEDIA AND URI WITHOUT MCC					153	DRG		Inpatient			21893.22	9851.95	9851.95	9851.95							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period	
ANALPRAM HC 2.5%	250	RC	A9270	CPT				Both			126	56.7	0.01	113.4	0.01							Fee Schedule		93.24							Fee Schedule																													113.4							Fee Schedule																																															
ANAMANTLE HC CREAM 0.5% UD	250	RC	A9270	CPT				Both			19.95	8.98	0.01	17.96	0.01							Fee Schedule		14.76							Fee Schedule																													17.96							Fee Schedule																																															
ANAPLASMA PHAGOCYTOPHILUM 17320 EDTA 3ML	300	RC	87798	CPT				Both			459.9	206.96	31.2	413.91	31.2							Fee Schedule		38.99							Fee Schedule		36.14							Fee Schedule		35.09							Fee Schedule		35.09							Fee Schedule		413.91							Fee Schedule		40.35							Fee Schedule		32.63							Fee Schedule		35.09							Fee Schedule		40.35							Fee Schedule		32.63							Fee Schedule		
ANASTROZOLE 1MG (ARIMIDEX) TABLET	250	RC	S0170	CPT				Both			6.21	2.79	0.48	5.59	0.48							Fee Schedule		4.6							Fee Schedule																													5.59							Fee Schedule																																															
ANCA SCRN WITH MPO & PR3 REFLEX 70159	302	RC	86036	CPT				Both			50	22.5	11.21	45	32.5							Fee Schedule		12.05							Fee Schedule		12.41							Fee Schedule		12.05							Fee Schedule		12.05							Fee Schedule		45							Fee Schedule		13.86							Fee Schedule		11.21							Fee Schedule		12.05							Fee Schedule		13.86							Fee Schedule		11.21							Fee Schedule		
ANDEXXA 200MG VIAL	636	RC	J7168	CPT				Both			9000	4050	1.95	8100		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	2.98							Fee Schedule		2.16							Fee Schedule											2.09							Fee Schedule		8100							Fee Schedule		2.41							Fee Schedule		1.95							Fee Schedule											2.41							Fee Schedule		1.95							Fee Schedule		
ANDROSTENEDIONE RIA 17182 SERUM	301	RC	82157	CPT				Both			165.9	74.66	26.02	149.31	26.02							Fee Schedule		32.53							Fee Schedule		30.16							Fee Schedule		29.28							Fee Schedule		29.28							Fee Schedule		149.31							Fee Schedule		33.67							Fee Schedule		27.23							Fee Schedule		29.28							Fee Schedule		33.67							Fee Schedule		27.23							Fee Schedule		
ANES BREATHING CIRCUIT 650904	271	RC						Both			10.5	4.73	4.73	9.45	6.83							Fee Schedule		7.77							Fee Schedule																													9.45							Fee Schedule																																															
ANES BREATHING CIRCUIT PEDIATRIC	271	RC						Both			14	6.3	6.3	12.6	9.1							Fee Schedule		10.36							Fee Schedule																													12.6							Fee Schedule																																															
ANES HOSES FOR VENT	271	RC						Both			24.15	10.87	10.87	21.74	15.7							Fee Schedule		17.87							Fee Schedule																													21.74							Fee Schedule																																															
ANES SYRINGE	272	RC						Both			9.45	4.25	4.25	8.51	6.14							Fee Schedule		6.99							Fee Schedule																													8.51							Fee Schedule																																															
ANES. NASOPHAR. AIRWAY 26FR #8888247023	271	RC						Both			10.5	4.73	4.73	9.45	6.83							Fee Schedule		7.77							Fee Schedule																													9.45							Fee Schedule																																															
ANES. NASOPHAR. AIRWAY 28FR #8888247031	271	RC						Both			13	5.85	5.85	11.7	8.45							Fee Schedule		9.62							Fee Schedule																													11.7							Fee Schedule																																															
ANES. NASOPHAR. AIRWAY 30FR #8888247049	271	RC						Both			13	5.85	5.85	11.7	8.45							Fee Schedule		9.62							Fee Schedule																													11.7							Fee Schedule																																															
ANES. NASOPHAR. AIRWAY 32FR #8888247056	271	RC						Both			10.5	4.73	4.73	9.45	6.83							Fee Schedule		7.77							Fee Schedule																													9.45							Fee Schedule																																															
ANES. NASOPHAR. AIRWAY 34FR #8888247064	271	RC						Both			5.25	2.36	2.36	4.73	3.41							Fee Schedule		3.89							Fee Schedule																													4.73							Fee Schedule																																															
ANES. NASOPHAR. AIRWAY 36FR #340090	271	RC						Both			16	7.2	7.2	14.4	10.4							Fee Schedule		11.84							Fee Schedule																													14.4							Fee Schedule																																															
ANESTH ADDT 15 FAC FEE	370	RC						Both			100	45	45	90	65							Fee Schedule		74							Fee Schedule																													90							Fee Schedule																																															
ANESTH INIT HR FAC FEE	370	RC						Both			1000	450	450	900	650							Fee Schedule		740							Fee Schedule																													900							Fee Schedule																																															
ANESTH. 2 LITER BAGS LATEX FREE	271	RC						Both			15.75	7.09	7.09	14.18	10.24							Fee Schedule		11.66							Fee Schedule																													14.18							Fee Schedule																																															
ANESTH. EXTENSION SET L.L. 2C8606 BAXTER	272	RC						Both			9	4.05	4.05	8.1	5.85							Fee Schedule		6.66							Fee Schedule																													8.1							Fee Schedule																																															
ANESTH. EXTENSION SET SLIP ADAPTOR BAXT.	272	RC						Both			2.1	0.95	0.95	1.89	1.37							Fee Schedule		1.55							Fee Schedule																													1.89							Fee Schedule																																															
ANESTH.CIRCUIT KIT 3 LTR.  DYNJAA10578	271	RC	A4618	CPT				Both			31	13.95	4.33	27.9	6.81							Fee Schedule		22.94							Fee Schedule		11.1							Fee Schedule		4.33							Fee Schedule		10.78							Fee Schedule		27.9							Fee Schedule		12.4							Fee Schedule		10.03							Fee Schedule											12.4							Fee Schedule		10.03							Fee Schedule		
ANESTHESIA ALTON DEAN HEAT EXCHANGER SET	272	RC						Both			34.65	15.59	15.59	31.19	22.52							Fee Schedule		25.64							Fee Schedule																													31.19							Fee Schedule																																															
ANESTHESIA BLOOD EXT SET	272	RC						Both			54.6	24.57	24.57	49.14	35.49							Fee Schedule		40.4							Fee Schedule																													49.14							Fee Schedule																																															
ANESTHESIA DUAL PURPOSE GUIDE WIRE BAXTE	272	RC						Both			22.05	9.92	9.92	19.85	14.33							Fee Schedule		16.32							Fee Schedule																													19.85							Fee Schedule																																															
ANESTHESIA EMERGENCY	370	RC	99140	CPT				Both			87.15	39.22	39.22	78.44	56.65							Fee Schedule		64.49							Fee Schedule																													78.44							Fee Schedule																																															
ANESTHESIA ENDO TUBE UNCUFFED 3.0	272	RC						Both			6.3	2.84	2.84	5.67	4.1							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
ANESTHESIA ENDO TUBE UNCUFFED 3.5	272	RC						Both			6.3	2.84	2.84	5.67	4.1							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
ANESTHESIA ENDO TUBE UNCUFFED 4.0	272	RC						Both			6.3	2.84	2.84	5.67	4.1							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
ANESTHESIA ENDO TUBE UNCUFFED 4.5	272	RC						Both			6.3	2.84	2.84	5.67	4.1							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
ANESTHESIA ENDO TUBE UNCUFFED 5.0	272	RC						Both			6.3	2.84	2.84	5.67	4.1							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
ANESTHESIA ENDO TUBE UNCUFFED 5.5	272	RC						Both			6.3	2.84	2.84	5.67	4.1							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
ANESTHESIA ENDO TUBE UNCUFFED 6.0	272	RC						Both			6.3	2.84	2.84	5.67	4.1							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
ANESTHESIA FOR OTHER PROCEDURES	370	RC	1999	CPT				Both			65	29.25	29.25	58.5	42.25							Fee Schedule		48.1							Fee Schedule																													58.5							Fee Schedule																																															
ANESTHESIA HIGH FLOW EXTENSION SET	272	RC						Both			11.55	5.2	5.2	10.4	7.51							Fee Schedule		8.55							Fee Schedule																													10.4							Fee Schedule																																															
ANESTHESIA NASAL RAE ENDO TUBE 6.0	272	RC						Both			11.55	5.2	5.2	10.4	7.51							Fee Schedule		8.55							Fee Schedule																													10.4							Fee Schedule																																															
ANESTHESIA NASAL RAE ENDO TUBE 7.0	272	RC						Both			11.55	5.2	5.2	10.4	7.51							Fee Schedule		8.55							Fee Schedule																													10.4							Fee Schedule																																															
ANESTHESIA NASOPHARYNGEAL AIRWAY 24FR	271	RC						Both			17.85	8.03	8.03	16.07	11.6							Fee Schedule		13.21							Fee Schedule																													16.07							Fee Schedule																																															
ANESTHESIA ORAL RAE CUFFED 4.0 86209	272	RC						Both			34	15.3	15.3	30.6	22.1							Fee Schedule		25.16							Fee Schedule																													30.6							Fee Schedule																																															
ANESTHESIA ORAL RAE CUFFED 4.5 86199	272	RC						Both			23	10.35	10.35	20.7	14.95							Fee Schedule		17.02							Fee Schedule																													20.7							Fee Schedule																																															
ANESTHESIA ORAL RAE CUFFED 5.0	272	RC						Both			13.65	6.14	6.14	12.29	8.87							Fee Schedule		10.1							Fee Schedule																													12.29							Fee Schedule																																															
ANESTHESIA ORAL RAE CUFFED 5.0 86267	272	RC						Both			7.35	3.31	3.31	6.62	4.78							Fee Schedule		5.44							Fee Schedule																													6.62							Fee Schedule																																															
ANESTHESIA ORAL RAE UNCUFFED 4.0 BAXTER	272	RC						Both			13.65	6.14	6.14	12.29	8.87							Fee Schedule		10.1							Fee Schedule																													12.29							Fee Schedule																																															
ANESTHESIA ORAL RAE UNCUFFED 4.5	272	RC						Both			7.35	3.31	3.31	6.62	4.78							Fee Schedule		5.44							Fee Schedule																													6.62							Fee Schedule																																															
ANESTHESIA ORAL RAE UNCUFFED 5.0 BAXTER	272	RC						Both			13.65	6.14	6.14	12.29	8.87							Fee Schedule		10.1							Fee Schedule																													12.29							Fee Schedule																																															
ANESTHESIA ORAL RAE UNCUFFED 5.5 BAXTER	272	RC						Both			13.65	6.14	6.14	12.29	8.87							Fee Schedule		10.1							Fee Schedule																													12.29							Fee Schedule																																															
ANESTHESIA ORAL RAE UNCUFFED 6.0 BAXTER	272	RC						Both			13.65	6.14	6.14	12.29	8.87							Fee Schedule		10.1							Fee Schedule																													12.29							Fee Schedule																																															
ANESTHESIA REGIONAL EXTENSION SET BAXT	272	RC						Both			11.55	5.2	5.2	10.4	7.51							Fee Schedule		8.55							Fee Schedule																													10.4							Fee Schedule																																															
ANESTHESIA SATIN SLIP STYLET 10FR  85864	272	RC						Both			20.25	9.11	9.11	18.23	13.16							Fee Schedule		14.99							Fee Schedule																													18.23							Fee Schedule																																															
ANESTHESIA SATIN SLIP STYLET 14FR 85865	272	RC						Both			11	4.95	4.95	9.9	7.15							Fee Schedule		8.14							Fee Schedule																													9.9							Fee Schedule																																															
ANESTHESIA SATIN SLIP STYLET 6FR. 85863	272	RC						Both			11	4.95	4.95	9.9	7.15							Fee Schedule		8.14							Fee Schedule																													9.9							Fee Schedule																																															
ANESTHESIA SINGLE SHOT EPIDURAL TRAY	272	RC						Both			78.75	35.44	35.44	70.88	51.19							Fee Schedule		58.28							Fee Schedule																													70.88							Fee Schedule																																															
ANESTHESIA SUCTION CATH 14 FR	272	RC						Both			3.15	1.42	1.42	2.84	2.05							Fee Schedule		2.33							Fee Schedule																													2.84							Fee Schedule																																															
ANESTHESIA T-CONNECTOR EXT SET BAXTER	271	RC						Both			7.35	3.31	3.31	6.62	4.78							Fee Schedule		5.44							Fee Schedule																													6.62							Fee Schedule																																															
ANESTHESIA UNDER 1YR/OVER 70	370	RC	99100	CPT				Both			87.15	39.22	39.22	78.44	56.65							Fee Schedule		64.49							Fee Schedule																													78.44							Fee Schedule																																															
ANGIOCATH 20G X 1.88  IV CATH #381137	272	RC						Both			16	7.2	7.2	14.4	10.4							Fee Schedule		11.84							Fee Schedule																													14.4							Fee Schedule																																															
ANGIOGRAPHIC CATHETER 5F VERT 150035VDR	272	RC						Both			169.05	76.07	76.07	152.15	109.88							Fee Schedule		125.1							Fee Schedule																													152.15							Fee Schedule																																															
ANGIOGRAPHIC CATHETER 5F VERT. 510035VER	272	RC						Both			33.6	15.12	15.12	30.24	21.84							Fee Schedule		24.86							Fee Schedule																													30.24							Fee Schedule																																															
ANGIOGRAPHIC CATHETER 5F VTK 1628-221	272	RC						Both			73	32.85	32.85	65.7	47.45							Fee Schedule		54.02							Fee Schedule																													65.7							Fee Schedule																																															
ANGIOGRAPHIC NEEDLE AD18T71WC	272	RC						Both			11	4.95	4.95	9.9	7.15							Fee Schedule		8.14							Fee Schedule																													9.9							Fee Schedule																																															
ANGIOGRAPHIC NEEDLE SL18T71W MERIT MEDIC	272	RC						Both			21	9.45	9.45	18.9	13.65							Fee Schedule		15.54							Fee Schedule																													18.9							Fee Schedule																																															
ANGIOSEAL VASC. CLOSURE  6FR.  610119	278	RC	C1760	CPT				Both			945	425.25	425.25	850.5		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	699.3							Fee Schedule																													850.5							Fee Schedule																																															
ANGIOSEAL VASC. CLOSURE  8FR.  610121	278	RC	C1760	CPT				Both			945	425.25	425.25	850.5		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	699.3							Fee Schedule																													850.5							Fee Schedule																																															
ANGIOTENSIN 1 CONVERT ENZ 683 SERUM	301	RC	82164	CPT				Both			80.85	36.38	12.98	72.77	12.98							Fee Schedule		16.22							Fee Schedule		15.04							Fee Schedule		14.6							Fee Schedule		14.6							Fee Schedule		72.77							Fee Schedule		16.79							Fee Schedule		13.58							Fee Schedule		14.6							Fee Schedule		16.79							Fee Schedule		13.58							Fee Schedule		
ANGIOTENSIN CONVERTING ENZ 34692 CSF	301	RC	82164	CPT				Both			80.85	36.38	12.98	72.77	12.98							Fee Schedule		16.22							Fee Schedule		15.04							Fee Schedule		14.6							Fee Schedule		14.6							Fee Schedule		72.77							Fee Schedule		16.79							Fee Schedule		13.58							Fee Schedule		14.6							Fee Schedule		16.79							Fee Schedule		13.58							Fee Schedule		
ANKLE BOOT ICE PACK PRO SERIES	274	RC	L1950	CPT				Both			177.98	80.09	80.09	984.31		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	131.71							Fee Schedule		881.6							Fee Schedule		673.8							Fee Schedule		855.92							Fee Schedule		160.18							Fee Schedule		984.31							Fee Schedule		796.01							Fee Schedule											984.31							Fee Schedule		796.01							Fee Schedule		
ANKLE BR PO LG	274	RC	L1990	CPT				Both			23.1	10.4	10.4	623.14		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	17.09							Fee Schedule		558.12							Fee Schedule		427.94							Fee Schedule		541.86							Fee Schedule		20.79							Fee Schedule		623.14							Fee Schedule		503.93							Fee Schedule											623.14							Fee Schedule		503.93							Fee Schedule		
ANKLE BR PO M	274	RC	L1990	CPT				Both			23.1	10.4	10.4	623.14		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	17.09							Fee Schedule		558.12							Fee Schedule		427.94							Fee Schedule		541.86							Fee Schedule		20.79							Fee Schedule		623.14							Fee Schedule		503.93							Fee Schedule											623.14							Fee Schedule		503.93							Fee Schedule		
ANKLE BR PO S	274	RC	L1990	CPT				Both			23.1	10.4	10.4	623.14		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	17.09							Fee Schedule		558.12							Fee Schedule		427.94							Fee Schedule		541.86							Fee Schedule		20.79							Fee Schedule		623.14							Fee Schedule		503.93							Fee Schedule											623.14							Fee Schedule		503.93							Fee Schedule		
ANKLE BRACE LACE-UP MEDIUM BLACK	274	RC	L1906	CPT				Both			96.34	43.35	43.35	181.61		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	71.29							Fee Schedule		162.66							Fee Schedule		110.34							Fee Schedule		157.92							Fee Schedule		86.71							Fee Schedule		181.61							Fee Schedule		146.87							Fee Schedule											181.61							Fee Schedule		146.87							Fee Schedule		
ANKLE BRACE ORTHO	274	RC	L4350	CPT				Both			169.05	76.07	76.07	152.15		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	125.1							Fee Schedule		124.45							Fee Schedule		94.55							Fee Schedule		120.83							Fee Schedule		152.15							Fee Schedule		138.95							Fee Schedule		112.37							Fee Schedule											138.95							Fee Schedule		112.37							Fee Schedule		
ANKLE BRACE STIRRUP 79-97867 NEW	270	RC						Both			35	15.75	15.75	31.5	22.75							Fee Schedule		25.9							Fee Schedule																													31.5							Fee Schedule																																															
ANKLE LT 3V	320	RC	73610	CPT				Both			315	141.75	15.33	318	18.51							Fee Schedule		22.27							Fee Schedule											15.33							Fee Schedule											283.5							Fee Schedule																				318							Per Diem																				
ANKLE RT 3V	320	RC	73610	CPT				Both			315	141.75	15.33	318	18.51							Fee Schedule		22.27							Fee Schedule											15.33							Fee Schedule											283.5							Fee Schedule																				318							Per Diem																				
ANOSCOPE DISP. 90X18  CO60100 DR. BRYANT	271	RC						Both			13.15	5.92	5.92	11.84	8.55							Fee Schedule		9.73							Fee Schedule																													11.84							Fee Schedule																																															
ANOSCOPE DISP. 96X23  CO60110 DR. BRYANT	271	RC						Both			13.15	5.92	5.92	11.84	8.55							Fee Schedule		9.73							Fee Schedule																													11.84							Fee Schedule																																															
ANOSCOPE DISPOSABLE	271	RC						Both			6.3	2.84	2.84	5.67	4.1							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
ANTI GLOMERULAR BASEMENT MEMBRANE AB 257	301	RC	83520	CPT				Both			321.3	144.59	12.43	289.17	12.43							Fee Schedule		17.27							Fee Schedule		17.79							Fee Schedule		17.27							Fee Schedule		17.27							Fee Schedule		289.17							Fee Schedule		19.86							Fee Schedule		16.06							Fee Schedule		17.27							Fee Schedule		19.86							Fee Schedule		16.06							Fee Schedule		
ANTI REFLUX VALVE #8888266197	272	RC	B9998	CPT				Both			10	4.5	4.5	9	6.5							Fee Schedule		7.4							Fee Schedule																													9							Fee Schedule																																															
ANTI RIBOSOMAL ANTI C 34283 SERUM  RT	301	RC	83520	CPT				Both			248.85	111.98	12.43	223.97	12.43							Fee Schedule		17.27							Fee Schedule		17.79							Fee Schedule		17.27							Fee Schedule		17.27							Fee Schedule		223.97							Fee Schedule		19.86							Fee Schedule		16.06							Fee Schedule		17.27							Fee Schedule		19.86							Fee Schedule		16.06							Fee Schedule		
ANTI STRIATED MUSCLE AB SCREEN 266 SERUM	302	RC	86255	CPT				Both			51.45	23.15	10.71	46.31	10.71							Fee Schedule		13.39							Fee Schedule		12.41							Fee Schedule		12.05							Fee Schedule		12.05							Fee Schedule		46.31							Fee Schedule		13.86							Fee Schedule		11.21							Fee Schedule		12.05							Fee Schedule		13.86							Fee Schedule		11.21							Fee Schedule		
ANTI STRIATED MUSCLE AB TITER 36210 SERU	302	RC	86256	CPT				Both			79.8	35.91	10.71	71.82	10.71							Fee Schedule		13.39							Fee Schedule		12.41							Fee Schedule		12.05							Fee Schedule		12.05							Fee Schedule		71.82							Fee Schedule		13.86							Fee Schedule		11.21							Fee Schedule		12.05							Fee Schedule		13.86							Fee Schedule		11.21							Fee Schedule		
ANTIBIOTIC BEADS #8400-0611 (WRIGHT MED)	278	RC	L8699	CPT				Both			2677.5	1204.88	1204.88	2409.75		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1981.35							Fee Schedule																													2409.75							Fee Schedule																																															
ANTIBODY PANEL	300	RC	86870	CPT				Both			134.4	60.48	29.66	120.96	29.66							Fee Schedule		40.59							Fee Schedule											36.67							Fee Schedule											120.96							Fee Schedule																																															
ANTIBODY SCREEN	300	RC	86850	CPT				Both			63	28.35	7.03	56.7	7.03							Fee Schedule		9.77							Fee Schedule		10.06							Fee Schedule		9.77							Fee Schedule		9.77							Fee Schedule		56.7							Fee Schedule		11.24							Fee Schedule		9.09							Fee Schedule		9.77							Fee Schedule		11.24							Fee Schedule		9.09							Fee Schedule		
ANTIBODY STAIN	300	RC	88344	CPT				Both			262	117.9	89.11	235.8	89.11							Fee Schedule		120.66							Fee Schedule											119.59							Fee Schedule											235.8							Fee Schedule																																															
ANTIBODY TITER 5149 LAV TOP (2)	300	RC	86886	CPT				Both			225.75	101.59	4.6	203.18	4.6							Fee Schedule		5.75							Fee Schedule		5.34							Fee Schedule		5.18							Fee Schedule		5.18							Fee Schedule		203.18							Fee Schedule		5.96							Fee Schedule		4.82							Fee Schedule		5.18							Fee Schedule		5.96							Fee Schedule		4.82							Fee Schedule		
ANTIENDOMYSIUM AB 15064 SERUM 1ML	301	RC	86255	CPT				Both			204.75	92.14	10.71	184.28	10.71							Fee Schedule		13.39							Fee Schedule		12.41							Fee Schedule		12.05							Fee Schedule		12.05							Fee Schedule		184.28							Fee Schedule		13.86							Fee Schedule		11.21							Fee Schedule		12.05							Fee Schedule		13.86							Fee Schedule		11.21							Fee Schedule		
ANTIFUNGAL CREAM REMEDY MSC094604	272	RC	A6250	CPT				Both			17.85	8.03	0.03	16.07	0.03							Fee Schedule		13.21							Fee Schedule																													16.07							Fee Schedule																																															
"ANTI-MULLERIAN HORMONE, FEMALE"	301	RC	83520	CPT				Both			306	137.7	12.43	275.4	12.43							Fee Schedule		17.27							Fee Schedule		17.79							Fee Schedule		17.27							Fee Schedule		17.27							Fee Schedule		275.4							Fee Schedule		19.86							Fee Schedule		16.06							Fee Schedule		17.27							Fee Schedule		19.86							Fee Schedule		16.06							Fee Schedule		
"ANTI-MULLERIAN HORMONE, MALE 37226"	301	RC	83520	CPT				Both			306	137.7	12.43	275.4	12.43							Fee Schedule		17.27							Fee Schedule		17.79							Fee Schedule		17.27							Fee Schedule		17.27							Fee Schedule		275.4							Fee Schedule		19.86							Fee Schedule		16.06							Fee Schedule		17.27							Fee Schedule		19.86							Fee Schedule		16.06							Fee Schedule		
ANTI-NAUSEA  LIQUID (EMETROL)	250	RC	A9270	CPT				Both			14.7	6.62	0.01	13.23	0.01							Fee Schedule		10.88							Fee Schedule																													13.23							Fee Schedule																																															
ANTIPYRINE/BENZOCAINE (AURALGAN) OTIC	250	RC	A9270	CPT				Both			40.67	18.3	0.01	36.6	0.01							Fee Schedule		30.1							Fee Schedule																													36.6							Fee Schedule																																															
ANTITHROMBIN III ACTIV 216 BLUE TUBE FZ	305	RC	85300	CPT				Both			68.25	30.71	10.53	61.43	10.53							Fee Schedule		13.17							Fee Schedule		12.21							Fee Schedule		11.85							Fee Schedule		11.85							Fee Schedule		61.43							Fee Schedule		13.63							Fee Schedule		11.02							Fee Schedule		11.85							Fee Schedule		13.63							Fee Schedule		11.02							Fee Schedule		
ANTITHROMBIN III AG 5158 FROZEN	305	RC	85301	CPT				Both			341.25	153.56	9.61	307.13	9.61							Fee Schedule		12.01							Fee Schedule		11.13							Fee Schedule		10.81							Fee Schedule		10.81							Fee Schedule		307.13							Fee Schedule		12.43							Fee Schedule		10.05							Fee Schedule		10.81							Fee Schedule		12.43							Fee Schedule		10.05							Fee Schedule		
ANTIVENIN LYOVAC	250	RC						Both			81.9	36.86	36.86	73.71	53.24							Fee Schedule		60.61							Fee Schedule																													73.71							Fee Schedule																																															
ANUMED RECTAL SUPPOSITORY	250	RC	A9270	CPT				Both			5.25	2.36	0.01	4.73	0.01							Fee Schedule		3.89							Fee Schedule																													4.73							Fee Schedule																																															
ANZEMET 12.5 MG/0.625ML AMPULE	636	RC	J1260	CPT				Both			68.25	30.71	30.71	61.43		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	50.51							Fee Schedule											38.54							Fee Schedule											61.43							Fee Schedule																																															
APAP WITH CODEINE ELIXIR-5ML UD	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
APAP/CODEINE (#3)300/30MG TABLET UD	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
APLIGRAF SKIN SUB 44CM (ORGANOGENESIS)	278	RC	Q4101	CPT				Both			87	39.15	39.15	146.21		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	64.38							Fee Schedule		130.95							Fee Schedule											127.14							Fee Schedule		78.3							Fee Schedule		146.21							Fee Schedule		118.24							Fee Schedule											146.21							Fee Schedule		118.24							Fee Schedule		
APOE GENOTYPE 10642 EDTA ROOM TEMP	300	RC	81401	CPT				Both			551.25	248.06	98.64	496.13	98.64							Fee Schedule		137							Fee Schedule		141.11							Fee Schedule		137							Fee Schedule		137							Fee Schedule		496.13							Fee Schedule		157.55							Fee Schedule		127.41							Fee Schedule		137							Fee Schedule		157.55							Fee Schedule		127.41							Fee Schedule		
APOLIPOPROTEIN  A1 5223	301	RC	82172	CPT				Both			105	47.25	15.18	94.5	15.18							Fee Schedule		21.09							Fee Schedule		21.72							Fee Schedule		21.09							Fee Schedule		21.09							Fee Schedule		94.5							Fee Schedule		24.25							Fee Schedule		19.61							Fee Schedule		21.09							Fee Schedule		24.25							Fee Schedule		19.61							Fee Schedule		
APOLIPOPROTEIN  B 5224	301	RC	82172	CPT				Both			15.75	7.09	7.09	24.25	15.18							Fee Schedule		21.09							Fee Schedule		21.72							Fee Schedule		21.09							Fee Schedule		21.09							Fee Schedule		14.18							Fee Schedule		24.25							Fee Schedule		19.61							Fee Schedule		21.09							Fee Schedule		24.25							Fee Schedule		19.61							Fee Schedule		
"OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITH CC"					155	DRG		Inpatient			46771.81	21047.31	21047.31	21047.31							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period	
DENTAL AND ORAL DISEASES WITH MCC					157	DRG		Inpatient			35759.54	16091.79	16091.79	16091.79							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period				13021.1	13021.1	13021.1	1 through 10									0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period	
DENTAL AND ORAL DISEASES WITHOUT CC/MCC					159	DRG		Inpatient			15738.19	7082.19	7082.19	7082.19							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback							0		No services provided during 15 month lookback period				2921.65	2921.65	2921.65	1 through 10			
APPLIED ALEXIS C8302	272	RC						Both			186	83.7	83.7	167.4	120.9							Fee Schedule		137.64							Fee Schedule																													167.4							Fee Schedule																																															
APPLIED ALEXIS C8312	272	RC						Both			186	83.7	83.7	167.4	120.9							Fee Schedule		137.64							Fee Schedule																													167.4							Fee Schedule																																															
APPLIED ALEXIS G6314	272	RC						Both			330	148.5	148.5	297	214.5							Fee Schedule		244.2							Fee Schedule																													297							Fee Schedule																																															
APPLIED ENDOPOUCH 15MM CD004	272	RC						Both			300	135	135	270	195							Fee Schedule		222							Fee Schedule																													270							Fee Schedule																																															
APPLIED ENDOPOUCH 5MM CD003	272	RC						Both			120	54	54	108	78							Fee Schedule		88.8							Fee Schedule																													108							Fee Schedule																																															
APPLIED GELPOINT MINI PLATFORM #CNGL3	272	RC						Both			2250	1012.5	1012.5	2025	1462.5							Fee Schedule		1665							Fee Schedule																													2025							Fee Schedule																																															
APPLIED MED. CLIP APPLIER #CA090 *DISC.*	272	RC						Both			499.8	224.91	224.91	449.82	324.87							Fee Schedule		369.85							Fee Schedule																													449.82							Fee Schedule																																															
APPLIED MED. SLEEVE 12X100 CTS22	272	RC						Both			41	18.45	18.45	36.9	26.65							Fee Schedule		30.34							Fee Schedule																													36.9							Fee Schedule																																															
APPLIED MED. TROCAR 12X100 CTF73 BLADELE	272	RC						Both			75	33.75	33.75	67.5	48.75							Fee Schedule		55.5							Fee Schedule																													67.5							Fee Schedule																																															
APPLIED MED. TROCAR 5X150 CTF01 BLADELES	272	RC						Both			57	25.65	25.65	51.3	37.05							Fee Schedule		42.18							Fee Schedule																													51.3							Fee Schedule																																															
APPLIED MEDICAL   CFS02	272	RC						Both			30	13.5	13.5	27	19.5							Fee Schedule		22.2							Fee Schedule																													27							Fee Schedule																																															
APPLIED MEDICAL 10MM DISP.CLIP APPLIER	272	RC						Both			253.05	113.87	113.87	227.75	164.48							Fee Schedule		187.26							Fee Schedule																													227.75							Fee Schedule																																															
APPLIED MEDICAL 120MM INSUF.NEEDLE C2201	272	RC						Both			42	18.9	18.9	37.8	27.3							Fee Schedule		31.08							Fee Schedule																													37.8							Fee Schedule																																															
APPLIED MEDICAL 12MM X 100  CO639	272	RC						Both			91.35	41.11	41.11	82.22	59.38							Fee Schedule		67.6							Fee Schedule																													82.22							Fee Schedule																																															
APPLIED MEDICAL 5MM X 100MM TROCAR CO512	272	RC						Both			56.7	25.52	25.52	51.03	36.86							Fee Schedule		41.96							Fee Schedule																													51.03							Fee Schedule																																															
APPLIED MEDICAL 5MM X 100MM TROCAR#CO957	272	RC						Both			112.35	50.56	50.56	101.12	73.03							Fee Schedule		83.14							Fee Schedule																													101.12							Fee Schedule																																															
APPLIED MEDICAL 5MM X 150MM TROCAR#CO908	272	RC						Both			85.05	38.27	38.27	76.55	55.28							Fee Schedule		62.94							Fee Schedule																													76.55							Fee Schedule																																															
APPLIED MEDICAL 8X100MM TROCAR #C0Q61	272	RC						Both			57	25.65	25.65	51.3	37.05							Fee Schedule		42.18							Fee Schedule																													51.3							Fee Schedule																																															
APPLIED MEDICAL CANNULA 12MM #CO632	272	RC						Both			68.25	30.71	30.71	61.43	44.36							Fee Schedule		50.51							Fee Schedule																													61.43							Fee Schedule																																															
APPLIED MEDICAL CLIP #CA500	272	RC						Both			255	114.75	114.75	229.5	165.75							Fee Schedule		188.7							Fee Schedule																													229.5							Fee Schedule																																															
APPLIED MEDICAL COR78/ NEW # CTS22	272	RC						Both			41	18.45	18.45	36.9	26.65							Fee Schedule		30.34							Fee Schedule																													36.9							Fee Schedule																																															
APPLIED MEDICAL CTF03 TROCAR CANN.	272	RC						Both			57	25.65	25.65	51.3	37.05							Fee Schedule		42.18							Fee Schedule																													51.3							Fee Schedule																																															
APPLIED MEDICAL EPIX SCISSORS # CB030	272	RC						Both			114	51.3	51.3	102.6	74.1							Fee Schedule		84.36							Fee Schedule																													102.6							Fee Schedule																																															
APPLIED MEDICAL HAND ACCESS C8XX2	272	RC						Both			2145	965.25	965.25	1930.5	1394.25							Fee Schedule		1587.3							Fee Schedule																													1930.5							Fee Schedule																																															
APPLIED MEDICAL LOW PROFILE SLEEVE CTS28	272	RC						Both			30	13.5	13.5	27	19.5							Fee Schedule		22.2							Fee Schedule																													27							Fee Schedule																																															
APPLIED MEDICAL RETRIEVAL SYS.# CD001	272	RC						Both			114	51.3	51.3	102.6	74.1							Fee Schedule		84.36							Fee Schedule																													102.6							Fee Schedule																																															
APPLIED MEDICAL SCOPE WARMER SEAL #C3101	272	RC						Both			20	9	9	18	13							Fee Schedule		14.8							Fee Schedule																													18							Fee Schedule																																															
APPLIED MEDICAL TROCAR 12X100 #CO682	272	RC						Both			118.65	53.39	53.39	106.79	77.12							Fee Schedule		87.8							Fee Schedule																													106.79							Fee Schedule																																															
APPLIED MEDICAL TROCAR 5X100 #CO957	272	RC						Both			85.05	38.27	38.27	76.55	55.28							Fee Schedule		62.94							Fee Schedule																													76.55							Fee Schedule																																															
APPLIED MEDICAL TROCAR 7MM  #CO723  .	272	RC						Both			135.45	60.95	60.95	121.91	88.04							Fee Schedule		100.23							Fee Schedule																													121.91							Fee Schedule																																															
APPLIED MEDICAL TROCAR CO641	272	RC						Both			81.9	36.86	36.86	73.71	53.24							Fee Schedule		60.61							Fee Schedule																													73.71							Fee Schedule																																															
APPLIED MEDICAL TROCAR CO736	272	RC						Both			85.05	38.27	38.27	76.55	55.28							Fee Schedule		62.94							Fee Schedule																													76.55							Fee Schedule																																															
APPLIED MEDICAL TROCAR SLEEVE CTS02	272	RC						Both			30	13.5	13.5	27	19.5							Fee Schedule		22.2							Fee Schedule																													27							Fee Schedule																																															
APPLIED MEDICAL11MM X 100MM CANNULA/SEAL	272	RC						Both			68.25	30.71	30.71	61.43	44.36							Fee Schedule		50.51							Fee Schedule																													61.43							Fee Schedule																																															
APPLIED MEDICAL11MM X 100MM TROCAR#CO667	272	RC						Both			130.2	58.59	58.59	117.18	84.63							Fee Schedule		96.35							Fee Schedule																													117.18							Fee Schedule																																															
APPLIED MEDICAL12MM X 100MM CANNULA/SEAL	272	RC						Both			68.25	30.71	30.71	61.43	44.36							Fee Schedule		50.51							Fee Schedule																													61.43							Fee Schedule																																															
APPLIED MEDICAL12MM X 100MM TROCAR#CO682	272	RC						Both			130.2	58.59	58.59	117.18	84.63							Fee Schedule		96.35							Fee Schedule																													117.18							Fee Schedule																																															
APPLIED MEDICAL12MM X 100MM TROCAR#CO727	272	RC						Both			169.05	76.07	76.07	152.15	109.88							Fee Schedule		125.1							Fee Schedule																													152.15							Fee Schedule																																															
APPLIED REPOSABLE GRASPER #C4120	272	RC						Both			210	94.5	94.5	189	136.5							Fee Schedule		155.4							Fee Schedule																													189							Fee Schedule																																															
APPLIED TROCAR 5X55 CTR21	272	RC						Both			57	25.65	25.65	51.3	37.05							Fee Schedule		42.18							Fee Schedule																													51.3							Fee Schedule																																															
APPLIED TROCAR 5X55 CTR24	272	RC						Both			87	39.15	39.15	78.3	56.55							Fee Schedule		64.38							Fee Schedule																													78.3							Fee Schedule																																															
APPLIED TROCAR NONBLADED COQ19	272	RC						Both			57	25.65	25.65	51.3	37.05							Fee Schedule		42.18							Fee Schedule																													51.3							Fee Schedule																																															
APPLIED VOYANT FUSION EB210	272	RC						Both			1275	573.75	573.75	1147.5	828.75							Fee Schedule		943.5							Fee Schedule																													1147.5							Fee Schedule																																															
APPLIED VOYANT FUSION EB215	272	RC						Both			1275	573.75	573.75	1147.5	828.75							Fee Schedule		943.5							Fee Schedule																													1147.5							Fee Schedule																																															
APPLIED VOYANT FUSION EB230	272	RC						Both			1275	573.75	573.75	1147.5	828.75							Fee Schedule		943.5							Fee Schedule																													1147.5							Fee Schedule																																															
APPLIED VOYANT FUSION EB240	272	RC						Both			1275	573.75	573.75	1147.5	828.75							Fee Schedule		943.5							Fee Schedule																													1147.5							Fee Schedule																																															
APPLIED XL ALEXIS C8404	272	RC						Both			330	148.5	148.5	297	214.5							Fee Schedule		244.2							Fee Schedule																													297							Fee Schedule																																															
APRESAZIDE 25/25 CAPSULE UD	250	RC	A9270	CPT				Both			5.25	2.36	0.01	4.73	0.01							Fee Schedule		3.89							Fee Schedule																													4.73							Fee Schedule																																															
APTT	305	RC	85730	CPT				Both			102.9	46.31	5.34	92.61	5.34							Fee Schedule		6.67							Fee Schedule		6.19							Fee Schedule		6.01							Fee Schedule		6.01							Fee Schedule		92.61							Fee Schedule		6.91							Fee Schedule		5.59							Fee Schedule		6.01							Fee Schedule		6.91							Fee Schedule		5.59							Fee Schedule		
AQUACEL 403765	272	RC	A6197	CPT				Both			29.4	13.23	13.23	26.96	14.8							Fee Schedule		21.76							Fee Schedule		24.14							Fee Schedule		18.5							Fee Schedule		23.44							Fee Schedule		26.46							Fee Schedule		26.96							Fee Schedule		21.8							Fee Schedule											26.96							Fee Schedule		21.8							Fee Schedule		
AQUACEL DRESSING SILVER 4X5 422299	272	RC	A6197	CPT				Both			22.65	10.19	10.19	26.96	14.8							Fee Schedule		16.76							Fee Schedule		24.14							Fee Schedule		18.5							Fee Schedule		23.44							Fee Schedule		20.39							Fee Schedule		26.96							Fee Schedule		21.8							Fee Schedule											26.96							Fee Schedule		21.8							Fee Schedule		
AQUACEL FOAM DRESSING 4X4  #420680	272	RC	A6197	CPT				Both			8	3.6	3.6	26.96	14.8							Fee Schedule		5.92							Fee Schedule		24.14							Fee Schedule		18.5							Fee Schedule		23.44							Fee Schedule		7.2							Fee Schedule		26.96							Fee Schedule		21.8							Fee Schedule											26.96							Fee Schedule		21.8							Fee Schedule		
AQUAPHOR OINT-1.75 OZ	250	RC	A9270	CPT				Both			19.85	8.93	0.01	17.87	0.01							Fee Schedule		14.69							Fee Schedule																													17.87							Fee Schedule																																															
ARANESP  40 MCG/ML VIAL	636	RC	J0881	CPT				Both			685.65	308.54	2.81	617.09		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	3.07							Fee Schedule		3.11							Fee Schedule											3.02							Fee Schedule		617.09							Fee Schedule		3.47							Fee Schedule		2.81							Fee Schedule											3.47							Fee Schedule		2.81							Fee Schedule		
ARANESP INJECTION SOLUTION 0.1MG/1ML	636	RC	J0881	CPT				Both			2786.4	1253.88	2.81	2507.76		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	3.07							Fee Schedule		3.11							Fee Schedule											3.02							Fee Schedule		2507.76							Fee Schedule		3.47							Fee Schedule		2.81							Fee Schedule											3.47							Fee Schedule		2.81							Fee Schedule		
ARANESP INJECTION SOLUTION 0.2MG/1ML	636	RC	J0881	CPT				Both			5572.8	2507.76	2.81	5015.52		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	3.07							Fee Schedule		3.11							Fee Schedule											3.02							Fee Schedule		5015.52							Fee Schedule		3.47							Fee Schedule		2.81							Fee Schedule											3.47							Fee Schedule		2.81							Fee Schedule		
ARFORMOTEROL TARTRATE 15MCG /2ML RESP UD	250	RC	A9270	CPT				Both			24.15	10.87	0.01	21.74	0.01							Fee Schedule		17.87							Fee Schedule																													21.74							Fee Schedule																																															
ARGATROBAN 100 MG//ML 2.5 ML SDV ESRD DI	636	RC	J0884	CPT				Both			1890	850.5	0.8	1701		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1398.6							Fee Schedule		0.89							Fee Schedule											0.86							Fee Schedule		1701							Fee Schedule		0.99							Fee Schedule		0.8							Fee Schedule											0.99							Fee Schedule		0.8							Fee Schedule		
ARGATROBAN 100 MG//ML 2.5 ML SDV NON ESR	636	RC	J0883	CPT				Both			4535.28	2040.88	0.57	4081.75		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1.02							Fee Schedule		0.63							Fee Schedule											0.61							Fee Schedule		4081.75							Fee Schedule		0.7							Fee Schedule		0.57							Fee Schedule											0.7							Fee Schedule		0.57							Fee Schedule		
ARGATROBAN 50 MG/50 ML (1 MG PER ML)	636	RC	J0884	CPT				Both			921.9	414.86	0.8	829.71		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	682.21							Fee Schedule		0.89							Fee Schedule											0.86							Fee Schedule		829.71							Fee Schedule		0.99							Fee Schedule		0.8							Fee Schedule											0.99							Fee Schedule		0.8							Fee Schedule		
ARICEPT  5MG (DONEPEZIL) TABLET	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
ARICEPT 10MG (DONEPEZIL) TABLET	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
ARIPIPRAZOLE (ABILIFY) 10MG TABLET	250	RC	A9270	CPT				Both			8.4	3.78	0.01	7.56	0.01							Fee Schedule		6.22							Fee Schedule																													7.56							Fee Schedule																																															
ARIPIPRAZOLE (ABILIFY) 2MG TAB	250	RC	A9270	CPT				Both			8.4	3.78	0.01	7.56	0.01							Fee Schedule		6.22							Fee Schedule																													7.56							Fee Schedule																																															
ARIPIPRAZOLE (ABILIFY) 5MG TABLET	250	RC	A9270	CPT				Both			8.4	3.78	0.01	7.56	0.01							Fee Schedule		6.22							Fee Schedule																													7.56							Fee Schedule																																															
ARISTA   1GM   HEMOSTATIC  SM0005	272	RC						Both			420	189	189	378	273							Fee Schedule		310.8							Fee Schedule																													378							Fee Schedule																																															
ARISTA  HEMOSTATIC   APPLICATOR   AM0005	272	RC						Both			89	40.05	40.05	80.1	57.85							Fee Schedule		65.86							Fee Schedule																													80.1							Fee Schedule																																															
ARISTA 3GM HEMOSTATIC SM0002-USA (DAVOL)	272	RC						Both			720	324	324	648	468							Fee Schedule		532.8							Fee Schedule																													648							Fee Schedule																																															
ARISTA 5GM HEMOSTATIC SM0007 (DAVOL)	272	RC						Both			1020	459	459	918	663							Fee Schedule		754.8							Fee Schedule																													918							Fee Schedule																																															
ARM BAND LASER PLS-102TE OR 7263  UAL	270	RC						Both			0.2	0.09	0.09	0.18	0.13							Fee Schedule		0.15							Fee Schedule																													0.18							Fee Schedule																																															
ARM IMMOBILIZER FEM LG #79-84047	274	RC						Both			18	8.1	8.1	16.2		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	13.32							Fee Schedule																													16.2							Fee Schedule																																															
ARM IMMOBILIZER FEM MED #79-84045	274	RC						Both			18	8.1	8.1	16.2		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	13.32							Fee Schedule																													16.2							Fee Schedule																																															
ARM IMMOBILIZER FEM SM #79-84043	274	RC						Both			17.07	7.68	7.68	15.36		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	12.63							Fee Schedule																													15.36							Fee Schedule																																															
ARM IMMOBILIZER FEM XL #79-84048	274	RC	L3677	CPT				Both			17.07	7.68	7.68	15.36		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	12.63							Fee Schedule																													15.36							Fee Schedule																																															
ARM IMMOBILIZER MALE LG #79-84037	274	RC	L3677	CPT				Both			18	8.1	8.1	16.2		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	13.32							Fee Schedule																													16.2							Fee Schedule																																															
ARM IMMOBILIZER MALE MED #79-84035	274	RC	L3677	CPT				Both			18	8.1	8.1	16.2		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	13.32							Fee Schedule																													16.2							Fee Schedule																																															
ARM IMMOBILIZER MALE SM #79-84033	274	RC	L3677	CPT				Both			17.1	7.7	7.7	15.39		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	12.65							Fee Schedule																													15.39							Fee Schedule																																															
ARM IMMOBILIZER MALE XL #79-84038	274	RC						Both			18	8.1	8.1	16.2		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	13.32							Fee Schedule																													16.2							Fee Schedule																																															
ARM IMMOBLIZER MED.	274	RC	L3677	CPT				Both			79.8	35.91	35.91	71.82		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	59.05							Fee Schedule																													71.82							Fee Schedule																																															
ARM SLING	274	RC	A4565	CPT				Both			32.76	14.74	8.66	29.48		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	24.24							Fee Schedule		11.31							Fee Schedule		8.66							Fee Schedule		10.98							Fee Schedule		29.48							Fee Schedule		12.63							Fee Schedule		10.21							Fee Schedule											12.63							Fee Schedule		10.21							Fee Schedule		
ARM SLING AND SWATHE LARGE 79-84247	274	RC						Both			24.4	10.98	10.98	21.96		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	18.06							Fee Schedule																													21.96							Fee Schedule																																															
ARM SLING AND SWATHE MEDIUM 79-84245	274	RC						Both			24.5	11.03	11.03	22.05		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	18.13							Fee Schedule																													22.05							Fee Schedule																																															
ARM SLING AND SWATHE SMALL 79-84243	274	RC						Both			24.5	11.03	11.03	22.05		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	18.13							Fee Schedule																													22.05							Fee Schedule																																															
ARM SLING AND SWATHE X-LARGE 79-84248	274	RC						Both			24.5	11.03	11.03	22.05		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	18.13							Fee Schedule																													22.05							Fee Schedule																																															
ARM SLING DELUXE LG #79-84007	274	RC						Both			8	3.6	3.6	7.2		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	5.92							Fee Schedule																													7.2							Fee Schedule																																															
ARM SLING DELUXE MED #79-84005	270	RC						Both			8	3.6	3.6	7.2	5.2							Fee Schedule		5.92							Fee Schedule																													7.2							Fee Schedule																																															
ARM SLING DELUXE PED 79-99132	274	RC	A4565	CPT				Both			17.85	8.03	8.03	16.07		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	13.21							Fee Schedule		11.31							Fee Schedule		8.66							Fee Schedule		10.98							Fee Schedule		16.07							Fee Schedule		12.63							Fee Schedule		10.21							Fee Schedule											12.63							Fee Schedule		10.21							Fee Schedule		
ARM SLING DELUXE SMALL #79-84003	270	RC						Both			8	3.6	3.6	7.2	5.2							Fee Schedule		5.92							Fee Schedule																													7.2							Fee Schedule																																															
ARM SLING DELUXE XL #79-84008	274	RC						Both			8	3.6	3.6	7.2		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	5.92							Fee Schedule																													7.2							Fee Schedule																																															
ARM SLING DELUXE XS #79-84002	270	RC						Both			8	3.6	3.6	7.2	5.2							Fee Schedule		5.92							Fee Schedule																													7.2							Fee Schedule																																															
ARM SLING DELUXE XXS #79-84001	274	RC	A4565	CPT				Both			8.98	4.04	4.04	12.63		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	6.65							Fee Schedule		11.31							Fee Schedule		8.66							Fee Schedule		10.98							Fee Schedule		8.08							Fee Schedule		12.63							Fee Schedule		10.21							Fee Schedule											12.63							Fee Schedule		10.21							Fee Schedule		
ARM SLING SHOULDER LG #11-0138-4-13130	274	RC	A4565	CPT				Both			143.85	64.73	8.66	129.47		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	106.45							Fee Schedule		11.31							Fee Schedule		8.66							Fee Schedule		10.98							Fee Schedule		129.47							Fee Schedule		12.63							Fee Schedule		10.21							Fee Schedule											12.63							Fee Schedule		10.21							Fee Schedule		
ARM SLING SHOULDER MED #11-0138-3-13130	274	RC	A4565	CPT				Both			139.65	62.84	8.66	125.69		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	103.34							Fee Schedule		11.31							Fee Schedule		8.66							Fee Schedule		10.98							Fee Schedule		125.69							Fee Schedule		12.63							Fee Schedule		10.21							Fee Schedule											12.63							Fee Schedule		10.21							Fee Schedule		
ARM SLING SHOULDER SM #11-0138-2-13130	274	RC	A4565	CPT				Both			141.75	63.79	8.66	127.58		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	104.9							Fee Schedule		11.31							Fee Schedule		8.66							Fee Schedule		10.98							Fee Schedule		127.58							Fee Schedule		12.63							Fee Schedule		10.21							Fee Schedule											12.63							Fee Schedule		10.21							Fee Schedule		
ARM SLING W/ABDUCTION PILLOW LARGE	274	RC						Both			143.85	64.73	64.73	129.47		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	106.45							Fee Schedule																													129.47							Fee Schedule																																															
ARM SLING W/ABDUCTION PILLOW MEDIUM	274	RC						Both			143.85	64.73	64.73	129.47		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	106.45							Fee Schedule																													129.47							Fee Schedule																																															
ARM SLING W/ABDUCTION PILLOW SMALL	270	RC						Both			143.85	64.73	64.73	129.47	93.5							Fee Schedule		106.45							Fee Schedule																													129.47							Fee Schedule																																															
ARM SLING/SWATHE LARGE #11-0138-4-13130	274	RC	A4565	CPT				Both			156.45	70.4	8.66	140.81		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	115.77							Fee Schedule		11.31							Fee Schedule		8.66							Fee Schedule		10.98							Fee Schedule		140.81							Fee Schedule		12.63							Fee Schedule		10.21							Fee Schedule											12.63							Fee Schedule		10.21							Fee Schedule		
ARM\SH IMMOB	274	RC	L3677	CPT				Both			79.8	35.91	35.91	71.82		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	59.05							Fee Schedule																													71.82							Fee Schedule																																															
ARROW GUIDE WIRE CN-04018	272	RC	C1769	CPT				Both			5.25	2.36	2.36	154.26	154.26							Fee Schedule		3.89							Fee Schedule																													4.73							Fee Schedule																																															
ARSENIC LEVEL 269 ROYAL BLUE TUBE	301	RC	82175	CPT				Both			105	47.25	16.86	94.5	16.86							Fee Schedule		21.08							Fee Schedule		19.54							Fee Schedule		18.97							Fee Schedule		18.97							Fee Schedule		94.5							Fee Schedule		21.82							Fee Schedule		17.64							Fee Schedule		18.97							Fee Schedule		21.82							Fee Schedule		17.64							Fee Schedule		
ARSENIC URINE RANDOM 270	301	RC	82175	CPT				Both			105	47.25	16.86	94.5	16.86							Fee Schedule		21.08							Fee Schedule		19.54							Fee Schedule		18.97							Fee Schedule		18.97							Fee Schedule		94.5							Fee Schedule		21.82							Fee Schedule		17.64							Fee Schedule		18.97							Fee Schedule		21.82							Fee Schedule		17.64							Fee Schedule		
ARTEGRAFT COLLAGEN VASCULAR GRAFT AG630	278	RC	C1768	CPT				Both			7887	3549.15	3549.15	7098.3		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	5836.38							Fee Schedule																													7098.3							Fee Schedule																																															
ARTEGRAFT COLLAGEN VASCULAR GRAFT AG740	278	RC	C1768	CPT				Both			7737	3481.65	3481.65	6963.3		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	5725.38							Fee Schedule																													6963.3							Fee Schedule																																															
ARTEGRAFT COLLAGEN VASCULAR GRAFT AG745	278	RC	C1768	CPT				Both			9537	4291.65	4291.65	8583.3		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	7057.38							Fee Schedule																													8583.3							Fee Schedule																																															
ARTEGRAFT COLLAGEN VASCULAR GRAFT AG750	278	RC	C1768	CPT				Both			10377	4669.65	4669.65	9339.3		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	7678.98							Fee Schedule																													9339.3							Fee Schedule																																															
ARTERIAL CATH OR CANNULATION			36620	CPT				Both			157.5	70.88	70.1	141.75	70.1							Fee Schedule		116.55							Fee Schedule																													141.75							Fee Schedule																																															
ARTERIAL NEEDLE AN-19GE	272	RC						Both			19	8.55	8.55	17.1	12.35							Fee Schedule		14.06							Fee Schedule																													17.1							Fee Schedule																																															
ARTERIAL PUNCTURE	370	RC	36600	CPT				Both			64.05	28.82	19.21	57.65	24.61							Fee Schedule		47.4							Fee Schedule											19.21							Fee Schedule											57.65							Fee Schedule																																															
ARTERIOGRAM	329	RC	75716	CPT				Both			519.75	233.89	74.87	467.78	81.1							Fee Schedule		74.87							Fee Schedule											356.77							Fee Schedule											467.78							Fee Schedule																				318							Per Diem																				
ARTHOGRAM ANKLE	320	RC	73615	CPT				Both			315	141.75	59.47	318	63.92							Fee Schedule		81.37							Fee Schedule											59.47							Fee Schedule											283.5							Fee Schedule																				318							Per Diem																				
ARTHOGRAM ELBOW	320	RC	73085	CPT				Both			315	141.75	54.9	318	54.9							Fee Schedule		70.33							Fee Schedule											59.47							Fee Schedule											283.5							Fee Schedule																				318							Per Diem																				
ARTHOGRAM HIP	320	RC	73525	CPT				Both			715.05	321.77	59.47	643.55	60.72							Fee Schedule		76.17							Fee Schedule											59.47							Fee Schedule											643.55							Fee Schedule																				318							Per Diem																				
ARTHOGRAM KNEE	320	RC	73580	CPT				Both			357	160.65	72.37	321.3	72.37							Fee Schedule		89.81							Fee Schedule											74.39							Fee Schedule											321.3							Fee Schedule																				318							Per Diem																				
ARTHOGRAM SHOULDER	320	RC	73040	CPT				Both			315	141.75	59.47	318	60.43							Fee Schedule		75.85							Fee Schedule											59.47							Fee Schedule											283.5							Fee Schedule																				318							Per Diem																				
ARTHOGRAM SI JOINT	320	RC	27096	CPT				Both			315	141.75	107.78	318	107.78							Fee Schedule		233.1							Fee Schedule																													283.5							Fee Schedule																				318							Per Diem																				
ARTHOGRAM WRIST	320	RC	73115	CPT				Both			315	141.75	44.71	318	64.21							Fee Schedule		81.69							Fee Schedule											44.71							Fee Schedule											283.5							Fee Schedule																				318							Per Diem																				
ARTHREX  #2 FIBERWIRE AR-7204	272	RC						Both			180.6	81.27	81.27	162.54	117.39							Fee Schedule		133.64							Fee Schedule																													162.54							Fee Schedule																																															
ARTHREX  #2 FIBERWIRE AR-7242	272	RC						Both			69.3	31.19	31.19	62.37	45.05							Fee Schedule		51.28							Fee Schedule																													62.37							Fee Schedule																																															
ARTHREX  CANNULA AR-6535	272	RC						Both			85.05	38.27	38.27	76.55	55.28							Fee Schedule		62.94							Fee Schedule																													76.55							Fee Schedule																																															
ARTHREX  CANNULA AR-6567	272	RC						Both			85.05	38.27	38.27	76.55	55.28							Fee Schedule		62.94							Fee Schedule																													76.55							Fee Schedule																																															
ARTHREX  CANNULA AR-6570	272	RC						Both			85.05	38.27	38.27	76.55	55.28							Fee Schedule		62.94							Fee Schedule																													76.55							Fee Schedule																																															
ARTHREX 2.4 DRILL BIT #AR-1250LT	272	RC						Both			281.4	126.63	126.63	253.26	182.91							Fee Schedule		208.24							Fee Schedule																													253.26							Fee Schedule																																															
ARTHREX 7CM CANNULA  # AR-6564	272	RC	C1713	CPT				Both			85.05	38.27	38.27	306.41	306.41							Fee Schedule		62.94							Fee Schedule																													76.55							Fee Schedule																																															
ARTHREX 7CM CANNULA AR-6566	272	RC	C1713	CPT				Both			85.05	38.27	38.27	306.41	306.41							Fee Schedule		62.94							Fee Schedule																													76.55							Fee Schedule																																															
ARTHREX 9CM CANNULA AR-6545	272	RC						Both			85.05	38.27	38.27	76.55	55.28							Fee Schedule		62.94							Fee Schedule																													76.55							Fee Schedule																																															
ARTHREX AR-6530	278	RC						Both			85.05	38.27	38.27	76.55		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	62.94							Fee Schedule																													76.55							Fee Schedule																																															
ARTHREX AR-6530	272	RC						Both			85.05	38.27	38.27	76.55	55.28							Fee Schedule		62.94							Fee Schedule																													76.55							Fee Schedule																																															
ARTHREX AR-7200	272	RC						Both			63	28.35	28.35	56.7	40.95							Fee Schedule		46.62							Fee Schedule																													56.7							Fee Schedule																																															
ARTHREX AR-7201	272	RC						Both			107.1	48.2	48.2	96.39	69.62							Fee Schedule		79.25							Fee Schedule																													96.39							Fee Schedule																																															
ARTHREX AR-7202	278	RC						Both			63	28.35	28.35	56.7		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	46.62							Fee Schedule																													56.7							Fee Schedule																																															
ARTHREX AR-7202	272	RC						Both			63	28.35	28.35	56.7	40.95							Fee Schedule		46.62							Fee Schedule																													56.7							Fee Schedule																																															
ARTHREX AR-7204	272	RC						Both			181.65	81.74	81.74	163.49	118.07							Fee Schedule		134.42							Fee Schedule																													163.49							Fee Schedule																																															
ARTHREX AR-7242	272	RC						Both			68.25	30.71	30.71	61.43	44.36							Fee Schedule		50.51							Fee Schedule																													61.43							Fee Schedule																																															
ARTHREX AR-9603A-90	272	RC	C1713	CPT				Both			472.5	212.63	212.63	425.25	306.41							Fee Schedule		349.65							Fee Schedule																													425.25							Fee Schedule																																															
ARTHREX BLADE AR-2285-10	272	RC						Both			158.55	71.35	71.35	142.7	103.06							Fee Schedule		117.33							Fee Schedule																													142.7							Fee Schedule																																															
ARTHREX FIBER TAPE SUTURE	272	RC						Both			157.5	70.88	70.88	141.75	102.38							Fee Schedule		116.55							Fee Schedule																													141.75							Fee Schedule																																															
ARTHREX FIBER TAPE SUTURE # AR-7237-7	272	RC						Both			152.25	68.51	68.51	137.03	98.96							Fee Schedule		112.67							Fee Schedule																													137.03							Fee Schedule																																															
ARTHREX FIBER WIRE	272	RC						Both			124.95	56.23	56.23	112.46	81.22							Fee Schedule		92.46							Fee Schedule																													112.46							Fee Schedule																																															
ARTHREX FIBERWIRE SUTURE #AR-7200	272	RC						Both			68.25	30.71	30.71	61.43	44.36							Fee Schedule		50.51							Fee Schedule																													61.43							Fee Schedule																																															
ARTHREX GUIDE PEN #AR1250L	272	RC						Both			101.85	45.83	45.83	91.67	66.2							Fee Schedule		75.37							Fee Schedule																													91.67							Fee Schedule																																															
ARTHREX GUIDE PEN #AR1254	272	RC						Both			68.25	30.71	30.71	61.43	44.36							Fee Schedule		50.51							Fee Schedule																													61.43							Fee Schedule																																															
ARTHREX GUIDE PEN #AR1297L	272	RC						Both			34.65	15.59	15.59	31.19	22.52							Fee Schedule		25.64							Fee Schedule																													31.19							Fee Schedule																																															
ARTHREX PART THREAD CANNULA #AR6564	272	RC						Both			90.3	40.64	40.64	81.27	58.7							Fee Schedule		66.82							Fee Schedule																													81.27							Fee Schedule																																															
ARTHREX SUTURE ANCHOR 5.0 #AR-1920SF	270	RC						Both			135.45	60.95	60.95	121.91	88.04							Fee Schedule		100.23							Fee Schedule																													121.91							Fee Schedule																																															
ARTHREX TWIST CANNULA #AR6530	272	RC						Both			90.3	40.64	40.64	81.27	58.7							Fee Schedule		66.82							Fee Schedule																													81.27							Fee Schedule																																															
ARTHREX TWIST-IN-CANNULA AR-6530	272	RC						Both			85.05	38.27	38.27	76.55	55.28							Fee Schedule		62.94							Fee Schedule																													76.55							Fee Schedule																																															
ARTHRO PUMP CARTRIDGE	272	RC						Both			169.05	76.07	76.07	152.15	109.88							Fee Schedule		125.1							Fee Schedule																													152.15							Fee Schedule																																															
ARTHROSCOPY PACK #DYNJP8150HD	270	RC						Both			127	57.15	57.15	114.3	82.55							Fee Schedule		93.98							Fee Schedule																													114.3							Fee Schedule																																															
ARTHROSCOPY PUMP CASSETTE	272	RC						Both			273	122.85	122.85	245.7	177.45							Fee Schedule		202.02							Fee Schedule																													245.7							Fee Schedule																																															
ARTHROTEC 50/0.2MG TABLET UD	250	RC	A9270	CPT				Both			4.2	1.89	0.01	3.78	0.01							Fee Schedule		3.11							Fee Schedule																													3.78							Fee Schedule																																															
ARTHROTEK PUMP CARTRIDGE	272	RC						Both			330.75	148.84	148.84	297.68	214.99							Fee Schedule		244.76							Fee Schedule																													297.68							Fee Schedule																																															
ARTLINE  RA-04020	272	RC						Both			27.3	12.29	12.29	24.57	17.75							Fee Schedule		20.2							Fee Schedule																													24.57							Fee Schedule																																															
ASCENSION 03 STEM   #MRH-350-03-WW	278	RC	C1776	CPT				Both			6237	2806.65	2806.65	5613.3		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	4615.38							Fee Schedule																													5613.3							Fee Schedule																																															
ASCENSION 24L HEAD  #MRH-350-24L-WW	278	RC	C1776	CPT				Both			6237	2806.65	2806.65	5613.3		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	4615.38							Fee Schedule																													5613.3							Fee Schedule																																															
ASCENSION 24S HEAD #MRH-350-24S-WW	278	RC	C1776	CPT				Both			5670	2551.5	2551.5	5103		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	4195.8							Fee Schedule																													5103							Fee Schedule																																															
ASCORBIC ACID 500MG/ML-50ML	636	RC	J3490	CPT				Both			17	7.65	7.65	15.3		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	12.58							Fee Schedule																													15.3							Fee Schedule																																															
ASEPTO SYRINGE	271	RC						Both			5.25	2.36	2.36	4.73	3.41							Fee Schedule		3.89							Fee Schedule																													4.73							Fee Schedule																																															
ASO TITER 265	302	RC	86060	CPT				Both			100.8	45.36	6.49	90.72	6.49							Fee Schedule		8.11							Fee Schedule		7.52							Fee Schedule		7.3							Fee Schedule		7.3							Fee Schedule		90.72							Fee Schedule		8.4							Fee Schedule		6.79							Fee Schedule		7.3							Fee Schedule		8.4							Fee Schedule		6.79							Fee Schedule		
ASP CHEMICAL INDICATOR STRIPS #14100	270	RC						Both			0.3	0.14	0.14	0.27	0.2							Fee Schedule		0.22							Fee Schedule																													0.27							Fee Schedule																																															
ASP VELOCITY BIOLOGICAL INDICATOR #43210	272	RC						Both			36	16.2	16.2	32.4	23.4							Fee Schedule		26.64							Fee Schedule																													32.4							Fee Schedule																																															
ASPEN DISP. RETURN MONITOR	272	RC						Both			15.75	7.09	7.09	14.18	10.24							Fee Schedule		11.66							Fee Schedule																													14.18							Fee Schedule																																															
ASPEN RETURN MONITOR CONMED #60-7203-002	272	RC						Both			15.75	7.09	7.09	14.18	10.24							Fee Schedule		11.66							Fee Schedule																													14.18							Fee Schedule																																															
ASPEN SUTURELESS CUTTING NEEDLE #212803	272	RC						Both			12.6	5.67	5.67	11.34	8.19							Fee Schedule		9.32							Fee Schedule																													11.34							Fee Schedule																																															
ASPEN SUTURELESS CUTTING NEEDLE #212805	272	RC						Both			12.6	5.67	5.67	11.34	8.19							Fee Schedule		9.32							Fee Schedule																													11.34							Fee Schedule																																															
ASPEN SUTURELESS NEEDLE #213406	272	RC						Both			20	9	9	18	13							Fee Schedule		14.8							Fee Schedule																													18							Fee Schedule																																															
ASPEN SUTURELESS NEEDLE TAPER #209510	272	RC						Both			12.6	5.67	5.67	11.34	8.19							Fee Schedule		9.32							Fee Schedule																													11.34							Fee Schedule																																															
ASPEN SUTURELESS NEEDLE TAPER #209514	272	RC						Both			14.7	6.62	6.62	13.23	9.56							Fee Schedule		10.88							Fee Schedule																													13.23							Fee Schedule																																															
"ASPERGILLUS AB, IMMUNO 20341"	302	RC	86606	CPT				Both			18	8.1	8.1	17.31	13.38							Fee Schedule		16.73							Fee Schedule		15.5							Fee Schedule		15.05							Fee Schedule		15.05							Fee Schedule		16.2							Fee Schedule		17.31							Fee Schedule		14							Fee Schedule		15.05							Fee Schedule		17.31							Fee Schedule		14							Fee Schedule		
"ASPERGILLUS ANTIGEN, EIA, SER 14950"	302	RC	87305	CPT				Both			315	141.75	10.66	283.5	10.66							Fee Schedule		13.32							Fee Schedule		12.34							Fee Schedule		11.98							Fee Schedule		11.98							Fee Schedule		283.5							Fee Schedule		13.78							Fee Schedule		11.14							Fee Schedule											13.78							Fee Schedule		11.14							Fee Schedule		
ASPERGILLUS FUMIGATUS IGE  2703	302	RC	86003	CPT				Both			15	6.75	4.64	13.5	4.64							Fee Schedule		5.8							Fee Schedule		5.38							Fee Schedule		5.22							Fee Schedule		5.22							Fee Schedule		13.5							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		5.22							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule		
ASPERGILLUS FUMIGATUS IGG 30163	302	RC	86606	CPT				Both			111	49.95	13.38	99.9	13.38							Fee Schedule		16.73							Fee Schedule		15.5							Fee Schedule		15.05							Fee Schedule		15.05							Fee Schedule		99.9							Fee Schedule		17.31							Fee Schedule		14							Fee Schedule		15.05							Fee Schedule		17.31							Fee Schedule		14							Fee Schedule		
ASPIRA CHEST TUBE DRAINAGE BAG 4992301	272	RC	A7040	CPT				Both			85.05	38.27	36.62	76.55	36.62							Fee Schedule		62.94							Fee Schedule		59.7							Fee Schedule											57.96							Fee Schedule		76.55							Fee Schedule		66.65							Fee Schedule		53.9							Fee Schedule											66.65							Fee Schedule		53.9							Fee Schedule		
ASPIRA DRAINAGE SYSTEM PLEURAL 4992507	272	RC	A7048	CPT				Both			3622.5	1630.13	38.3	3260.25	38.3							Fee Schedule		2680.65							Fee Schedule		62.45							Fee Schedule											60.63							Fee Schedule		3260.25							Fee Schedule		69.72							Fee Schedule		56.39							Fee Schedule											69.72							Fee Schedule		56.39							Fee Schedule		
ASPIRA PERITONEAL DRAINAGE #4992207	272	RC						Both			3572	1607.4	1607.4	3214.8	2321.8							Fee Schedule		2643.28							Fee Schedule																													3214.8							Fee Schedule																																															
ASPIRA PERITONEAL DRAINAGE #4992209	272	RC						Both			2973	1337.85	1337.85	2675.7	1932.45							Fee Schedule		2200.02							Fee Schedule																													2675.7							Fee Schedule																																															
ASPIRATOR NEEDLE 21G MAJ065.A	272	RC						Both			160.02	72.01	72.01	144.02	104.01							Fee Schedule		118.41							Fee Schedule																													144.02							Fee Schedule																																															
ASPIRATOR NEEDLE 21G MAJ066.A	272	RC						Both			160.02	72.01	72.01	144.02	104.01							Fee Schedule		118.41							Fee Schedule																													144.02							Fee Schedule																																															
ASPIRIN  300 MG SUPPOSITORY	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
ASPIRIN  81 MG CHEWABLE TABLET	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
ASPIRIN 300 MG SUPPOSITORY	250	RC	A9270	CPT				Both			5.25	2.36	0.01	4.73	0.01							Fee Schedule		3.89							Fee Schedule																													4.73							Fee Schedule																																															
ASPIRIN 325 MG TABLET	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
ASPIRIN ENTERIC COATED  81 MG TABLET	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
ASPIRIN ENTERIC COATED 325 MG TABLET	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
ATENOLOL 25 MG (TENORMIN) TABLET	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
ATENOLOL 50 MG (TENORMIN) TABLET	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
ATORVASTATIN (LIPITOR) 10MG TABLET	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
ATORVASTATIN (LIPITOR) 20MG TABLET	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
ATORVASTATIN (LIPITOR) 40MG TABLET	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
ATOVAQUONE 750 MG/5ML SUSP- 5ML UD	250	RC	A9270	CPT				Both			66.15	29.77	0.01	59.54	0.01							Fee Schedule		48.95							Fee Schedule																													59.54							Fee Schedule																																															
ATRACURIUM 10 MG/ML-5ML MDV	250	RC						Both			21	9.45	9.45	18.9	13.65							Fee Schedule		15.54							Fee Schedule																													18.9							Fee Schedule																																															
ATRIPLA 200-300-600 TABLET UD	250	RC	A9270	CPT				Both			156.45	70.4	0.01	140.81	0.01							Fee Schedule		115.77							Fee Schedule																													140.81							Fee Schedule																																															
ATRIUM STRAIGHT TUBE M00202166168PO	272	RC	C1768	CPT				Both			2064.3	928.94	322.77	1857.87	322.77							Fee Schedule		1527.58							Fee Schedule																													1857.87							Fee Schedule																																															
ATRIUM STRAIGHT TUBE M00202166201PO	272	RC	C1768	CPT				Both			2064.3	928.94	322.77	1857.87	322.77							Fee Schedule		1527.58							Fee Schedule																													1857.87							Fee Schedule																																															
ATRIUM STRAIGHT TUBE M00202175206PO	272	RC	C1768	CPT				Both			1507.8	678.51	322.77	1357.02	322.77							Fee Schedule		1115.77							Fee Schedule																													1357.02							Fee Schedule																																															
ATROPINE 0.05MG/ML PEDIATRIC 5 ML PFS	636	RC	J0461	CPT				Both			48.3	21.74	0.1	43.47		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	35.74							Fee Schedule		0.12							Fee Schedule											0.11							Fee Schedule		43.47							Fee Schedule		0.13							Fee Schedule		0.1							Fee Schedule											0.13							Fee Schedule		0.1							Fee Schedule		
ATROPINE 0.1MG/ML  5 ML PFS	636	RC	J0461	CPT				Both			53.4	24.03	0.1	48.06		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	39.52							Fee Schedule		0.12							Fee Schedule											0.11							Fee Schedule		48.06							Fee Schedule		0.13							Fee Schedule		0.1							Fee Schedule											0.13							Fee Schedule		0.1							Fee Schedule		
ATROPINE 0.1MG/ML 10ML PF SYRINGE	636	RC	J0461	CPT				Both			18.9	8.51	0.1	17.01		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	13.99							Fee Schedule		0.12							Fee Schedule											0.11							Fee Schedule		17.01							Fee Schedule		0.13							Fee Schedule		0.1							Fee Schedule											0.13							Fee Schedule		0.1							Fee Schedule		
ATROPINE 0.4 MG/ML- 20ML VIAL	636	RC	J0461	CPT				Both			134.4	60.48	0.1	120.96		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	99.46							Fee Schedule		0.12							Fee Schedule											0.11							Fee Schedule		120.96							Fee Schedule		0.13							Fee Schedule		0.1							Fee Schedule											0.13							Fee Schedule		0.1							Fee Schedule		
ATROPINE 0.4 MG/ML-1ML VIAL	636	RC	J0461	CPT				Both			27.3	12.29	0.1	24.57		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	20.2							Fee Schedule		0.12							Fee Schedule											0.11							Fee Schedule		24.57							Fee Schedule		0.13							Fee Schedule		0.1							Fee Schedule											0.13							Fee Schedule		0.1							Fee Schedule		
ATROPINE 1% OPTH SOL	250	RC	A9270	CPT				Both			176.4	79.38	0.01	158.76	0.01							Fee Schedule		130.54							Fee Schedule																													158.76							Fee Schedule																																															
ATROVENT HFA 12.9 GRAMS	250	RC	J3535	CPT				Both			541.8	243.81	243.81	487.62	352.17							Fee Schedule		400.93							Fee Schedule																													487.62							Fee Schedule																																															
ATROVENT NASAL SPRAY .06%-15ML	250	RC						Both			140.77	63.35	63.35	126.69	91.5							Fee Schedule		104.17							Fee Schedule																													126.69							Fee Schedule																																															
ATS CANISTER WITH GEL M6275063/5	272	RC	A7000	CPT				Both			135.45	60.95	6.56	121.91	6.56							Fee Schedule		100.23							Fee Schedule		10.82							Fee Schedule											10.5							Fee Schedule		121.91							Fee Schedule		12.08							Fee Schedule		9.77							Fee Schedule											12.08							Fee Schedule		9.77							Fee Schedule		
AUGMENTIN 125 MG/5 ML ORAL SUSP-75ML	250	RC	A9270	CPT				Both			79.8	35.91	0.01	71.82	0.01							Fee Schedule		59.05							Fee Schedule																													71.82							Fee Schedule																																															
AUGMENTIN 250 MG/5ML  SUSP-100ML	250	RC	A9270	CPT				Both			202.65	91.19	0.01	182.39	0.01							Fee Schedule		149.96							Fee Schedule																													182.39							Fee Schedule																																															
AUGMENTIN 250 MG/5ML-75ML SUSP.	250	RC	A9270	CPT				Both			152.25	68.51	0.01	137.03	0.01							Fee Schedule		112.67							Fee Schedule																													137.03							Fee Schedule																																															
AUGMENTIN XR 1000MG/62.5MG ER TABLETS	250	RC	A9270	CPT				Both			10.5	4.73	0.01	9.45	0.01							Fee Schedule		7.77							Fee Schedule																													9.45							Fee Schedule																																															
AUTO IMMUNE INNER EAR AG WILD 143 MANUAL	301	RC	84182	CPT				Both			387.45	174.35	21.03	348.71	21.03							Fee Schedule		29.21							Fee Schedule		30.09							Fee Schedule		29.21							Fee Schedule		29.21							Fee Schedule		348.71							Fee Schedule		33.59							Fee Schedule		27.17							Fee Schedule		29.21							Fee Schedule		33.59							Fee Schedule		27.17							Fee Schedule		
AUTO SUT.OVAL PREP.DIST.BALN. OMS-PDBS2	272	RC						Both			1688	759.6	759.6	1519.2	1097.2							Fee Schedule		1249.12							Fee Schedule																													1519.2							Fee Schedule																																															
AUTO SUT.STRUCT.BALLN.TROC.#OMST10SB	272	RC						Both			1055.73	475.08	475.08	950.16	686.22							Fee Schedule		781.24							Fee Schedule																													950.16							Fee Schedule																																															
AUTO SUTURE  TROCAR OMS-T10SB	272	RC						Both			996	448.2	448.2	896.4	647.4							Fee Schedule		737.04							Fee Schedule																													896.4							Fee Schedule																																															
AUTO SUTURE BLUNT TIP TROCAR OMS-T12BT	272	RC						Both			793	356.85	356.85	713.7	515.45							Fee Schedule		586.82							Fee Schedule																													713.7							Fee Schedule																																															
AUTO SUTURE ROUND BALLON OMS-PDB1000	272	RC						Both			1704	766.8	766.8	1533.6	1107.6							Fee Schedule		1260.96							Fee Schedule																													1533.6							Fee Schedule																																															
AUTO SUTURE TA 90 STAPLER 015084	272	RC						Both			719.25	323.66	323.66	647.33	467.51							Fee Schedule		532.25							Fee Schedule																													647.33							Fee Schedule																																															
AUTOTOME RX 20MM #M00545170	272	RC						Both			707	318.15	318.15	636.3	459.55							Fee Schedule		523.18							Fee Schedule																													636.3							Fee Schedule																																															
AUTOTOME RX 30MM #M00545180	272	RC						Both			670	301.5	301.5	603	435.5							Fee Schedule		495.8							Fee Schedule																													603							Fee Schedule																																															
AUTOTOME RX 49 20MM #M00545150	272	RC						Both			669	301.05	301.05	602.1	434.85							Fee Schedule		495.06							Fee Schedule																													602.1							Fee Schedule																																															
AUTOTOME RX 49 30MM #M00545160	272	RC						Both			669	301.05	301.05	602.1	434.85							Fee Schedule		495.06							Fee Schedule																													602.1							Fee Schedule																																															
AVAC 1500CC PURCHASING #71-8003	271	RC	A7000	CPT				Both			5	2.25	2.25	12.08	6.56							Fee Schedule		3.7							Fee Schedule		10.82							Fee Schedule											10.5							Fee Schedule		4.5							Fee Schedule		12.08							Fee Schedule		9.77							Fee Schedule											12.08							Fee Schedule		9.77							Fee Schedule		
AVAC 2500CC #71-8004	271	RC	A7000	CPT				Both			6	2.7	2.7	12.08	6.56							Fee Schedule		4.44							Fee Schedule		10.82							Fee Schedule											10.5							Fee Schedule		5.4							Fee Schedule		12.08							Fee Schedule		9.77							Fee Schedule											12.08							Fee Schedule		9.77							Fee Schedule		
AVANIDA 4 MG (ROSIGLITAZONE) TABLET	250	RC						Both			11.55	5.2	5.2	10.4	7.51							Fee Schedule		8.55							Fee Schedule																													10.4							Fee Schedule																																															
AVANOS DECLOGGING SYSTEM 20-0002	272	RC						Both			69.3	31.19	31.19	62.37	45.05							Fee Schedule		51.28							Fee Schedule																													62.37							Fee Schedule																																															
AVANOS GASTRO FEEDING TUBE 28FR 8100-28	272	RC	B4088	CPT				Both			122	54.9	16.34	109.8	16.34							Fee Schedule		90.28							Fee Schedule																													109.8							Fee Schedule																																															
AVANOS JEJUNAL FEED TUBE 16FR. 0200-16	272	RC						Both			446	200.7	200.7	401.4	289.9							Fee Schedule		330.04							Fee Schedule																													401.4							Fee Schedule																																															
AVANOS JEJUNAL FEED TUBE 18FR. 0200-18	272	RC						Both			425.25	191.36	191.36	382.73	276.41							Fee Schedule		314.69							Fee Schedule																													382.73							Fee Schedule																																															
AVANOS JEJUNAL FEED TUBE 8140-24-2.5	272	RC						Both			342	153.9	153.9	307.8	222.3							Fee Schedule		253.08							Fee Schedule																													307.8							Fee Schedule																																															
AVANOS JEJUNAL FEED TUBE 8140-24-4.0	272	RC						Both			342	153.9	153.9	307.8	222.3							Fee Schedule		253.08							Fee Schedule																													307.8							Fee Schedule																																															
AVANOS JEJUNAL FEED TUBE 8270-18-2.7-30	272	RC						Both			1139	512.55	512.55	1025.1	740.35							Fee Schedule		842.86							Fee Schedule																													1025.1							Fee Schedule																																															
AVANOS JEJUNAL FEED TUBE 8270-22-2.7-45	272	RC						Both			1139	512.55	512.55	1025.1	740.35							Fee Schedule		842.86							Fee Schedule																													1025.1							Fee Schedule																																															
AVANOS JEJUNAL FEED TUBE 8270-22-3.5-45	272	RC						Both			1139	512.55	512.55	1025.1	740.35							Fee Schedule		842.86							Fee Schedule																													1025.1							Fee Schedule																																															
AVANOS JEJUNAL INTRODUCER KIT 98433	272	RC	C1887	CPT				Both			688.8	309.96	43.86	619.92	43.86							Fee Schedule		509.71							Fee Schedule																													619.92							Fee Schedule																																															
AVANOS JEJUNAL INTRODUCER KIT 98437	272	RC	C1887	CPT				Both			688.8	309.96	43.86	619.92	43.86							Fee Schedule		509.71							Fee Schedule																													619.92							Fee Schedule																																															
AVANOS JEJUNAL INTRODUCER KIT 98438	272	RC	C1887	CPT				Both			709	319.05	43.86	638.1	43.86							Fee Schedule		524.66							Fee Schedule																													638.1							Fee Schedule																																															
AVAPRO 150 MG (IRBESARTAN) TABLET	250	RC	A9270	CPT				Both			9.45	4.25	0.01	8.51	0.01							Fee Schedule		6.99							Fee Schedule																													8.51							Fee Schedule																																															
AVC CREAM 15%-4OZ	250	RC	A9270	CPT				Both			285.01	128.25	0.01	256.51	0.01							Fee Schedule		210.91							Fee Schedule																													256.51							Fee Schedule																																															
AVEED INTRAMUSCULAR SOLUTION 250MG/1ML	636	RC	J3145	CPT				Both			7115.79	3202.11	1.92	6404.21		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	2.13							Fee Schedule		2.13							Fee Schedule											2.07							Fee Schedule		6404.21							Fee Schedule		2.38							Fee Schedule		1.92							Fee Schedule											2.38							Fee Schedule		1.92							Fee Schedule		
AVEENO OATMEAL BATH	250	RC	A9270	CPT				Both			25.96	11.68	0.01	23.36	0.01							Fee Schedule		19.21							Fee Schedule																													23.36							Fee Schedule																																															
AVERAGE MED BLADE 111	272	RC						Both			129.15	58.12	58.12	116.24	83.95							Fee Schedule		95.57							Fee Schedule																													116.24							Fee Schedule																																															
AVERAGE MED BLADE STRYKER #2296-3-111	272	RC						Both			129.15	58.12	58.12	116.24	83.95							Fee Schedule		95.57							Fee Schedule																													116.24							Fee Schedule																																															
AVODART 0.5MG (DUTASTERIDE) GEL CAPSULE	250	RC	A9270	CPT				Both			18.9	8.51	0.01	17.01	0.01							Fee Schedule		13.99							Fee Schedule																													17.01							Fee Schedule																																															
AXIOS STENT W/ DELIVERY SYSTEM M00553750	278	RC	C1874	CPT				Both			12324	5545.8	5545.8	11091.6		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	9119.76							Fee Schedule																													11091.6							Fee Schedule																																															
AXONICS EXTERNAL TRIAL STIMULATOR #1601	270	RC						Both			660	297	297	594	429							Fee Schedule		488.4							Fee Schedule																													594							Fee Schedule																																															
AXONICS PERCUTANEOUS EXTENSION #9009	272	RC						Both			288	129.6	129.6	259.2	187.2							Fee Schedule		213.12							Fee Schedule																													259.2							Fee Schedule																																															
AZATHIOPRINE 50 MG  (IMURAN) TABLET	636	RC	J7500	CPT				Both			6.3	2.84	0.13	5.67		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	4.66							Fee Schedule		0.14							Fee Schedule											0.14							Fee Schedule		5.67							Fee Schedule		0.16							Fee Schedule		0.13							Fee Schedule											0.16							Fee Schedule		0.13							Fee Schedule		
AZELASTINE NASAL SPRAY (ASTELIN)- 30ML	250	RC	A9270	CPT				Both			331.8	149.31	0.01	298.62	0.01							Fee Schedule		245.53							Fee Schedule																													298.62							Fee Schedule																																															
AZITHROMYCIN  500MG /NS 250 ML IVPB	636	RC	J0456	CPT				Both			122.85	55.28	1.76	110.57		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	90.91							Fee Schedule		1.95							Fee Schedule											1.89							Fee Schedule		110.57							Fee Schedule		2.17							Fee Schedule		1.76							Fee Schedule											2.17							Fee Schedule		1.76							Fee Schedule		
AZITHROMYCIN 100 MG/5 ML SUSPS.-15ML	250	RC	A9270	CPT				Both			110.25	49.61	0.01	99.23	0.01							Fee Schedule		81.59							Fee Schedule																													99.23							Fee Schedule																																															
AZITHROMYCIN 200 MG/5ML ORAL SUSP-30ML	250	RC	Q0144	CPT				Both			110.25	49.61	24.18	99.23	24.18							Fee Schedule		81.59							Fee Schedule																													99.23							Fee Schedule																																															
AZITHROMYCIN 250 MG TABLET UD	250	RC	A9270	CPT				Both			8.4	3.78	0.01	7.56	0.01							Fee Schedule		6.22							Fee Schedule																													7.56							Fee Schedule																																															
AZITHROMYCIN 500MG VIAL	636	RC	J0456	CPT				Both			18.9	8.51	1.76	17.01		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	13.99							Fee Schedule		1.95							Fee Schedule											1.89							Fee Schedule		17.01							Fee Schedule		2.17							Fee Schedule		1.76							Fee Schedule											2.17							Fee Schedule		1.76							Fee Schedule		
AZMACORT 100 MCG MD INHALER-20GM	636	RC	J3535	CPT				Both			495.4	222.93	222.93	445.86		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	366.6							Fee Schedule																													445.86							Fee Schedule																																															
AZOPT 1% OPTH SUSP- 10ML	250	RC	A9270	CPT				Both			1165.5	524.48	0.01	1048.95	0.01							Fee Schedule		862.47							Fee Schedule																													1048.95							Fee Schedule																																															
AZTREONAM  1 GM (AZACTAM) VIAL	250	RC	J0457	CPT				Both			124.95	56.23	2.11	112.46	81.22							Fee Schedule		92.46							Fee Schedule		2.34							Fee Schedule											2.27							Fee Schedule		112.46							Fee Schedule		2.61							Fee Schedule		2.11							Fee Schedule											2.61							Fee Schedule		2.11							Fee Schedule		
AZTREONAM  1 GM/NS 100 ML IVPB	250	RC	J0457	CPT				Both			137.55	61.9	2.11	123.8	89.41							Fee Schedule		101.79							Fee Schedule		2.34							Fee Schedule											2.27							Fee Schedule		123.8							Fee Schedule		2.61							Fee Schedule		2.11							Fee Schedule											2.61							Fee Schedule		2.11							Fee Schedule		
AZTREONAM  2 GM (AZACTAM) VIAL	250	RC	J0457	CPT				Both			206.85	93.08	2.11	186.17	134.45							Fee Schedule		153.07							Fee Schedule		2.34							Fee Schedule											2.27							Fee Schedule		186.17							Fee Schedule		2.61							Fee Schedule		2.11							Fee Schedule											2.61							Fee Schedule		2.11							Fee Schedule		
AZTREONAM  2 GM/ NS 100 ML IVPB	250	RC	J0457	CPT				Both			257.25	115.76	2.11	231.53	167.21							Fee Schedule		190.37							Fee Schedule		2.34							Fee Schedule											2.27							Fee Schedule		231.53							Fee Schedule		2.61							Fee Schedule		2.11							Fee Schedule											2.61							Fee Schedule		2.11							Fee Schedule		
AZTREONAM 250MG/NS 50 ML IVPB	636	RC	J0457	CPT				Both			137.55	61.9	2.11	123.8		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	101.79							Fee Schedule		2.34							Fee Schedule											2.27							Fee Schedule		123.8							Fee Schedule		2.61							Fee Schedule		2.11							Fee Schedule											2.61							Fee Schedule		2.11							Fee Schedule		
AZTREONAM 500MG/NS 100 ML IVPB	636	RC	J0457	CPT				Both			137.55	61.9	2.11	123.8		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	101.79							Fee Schedule		2.34							Fee Schedule											2.27							Fee Schedule		123.8							Fee Schedule		2.61							Fee Schedule		2.11							Fee Schedule											2.61							Fee Schedule		2.11							Fee Schedule		
B 12 VITAMIN LEVEL	301	RC	82607	CPT				Both			109.2	49.14	13.4	98.28	13.4							Fee Schedule		16.75							Fee Schedule		15.53							Fee Schedule		15.08							Fee Schedule		15.08							Fee Schedule		98.28							Fee Schedule		17.34							Fee Schedule		14.02							Fee Schedule		15.08							Fee Schedule		17.34							Fee Schedule		14.02							Fee Schedule		
B PLATE MINI SET USE	278	RC						Both			170.1	76.55	76.55	153.09		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	125.87							Fee Schedule																													153.09							Fee Schedule																																															
B2 GLYCOPROTEIN I AB IGA 36552	300	RC	86146	CPT				Both			108.15	48.67	22.62	97.34	22.62							Fee Schedule		28.28							Fee Schedule		26.21							Fee Schedule		25.45							Fee Schedule		25.45							Fee Schedule		97.34							Fee Schedule		29.27							Fee Schedule		23.67							Fee Schedule		25.45							Fee Schedule		29.27							Fee Schedule		23.67							Fee Schedule		
B2 GLYCOPROTEIN I AB IGG 36554 RT	300	RC	86146	CPT				Both			108.15	48.67	22.62	97.34	22.62							Fee Schedule		28.28							Fee Schedule		26.21							Fee Schedule		25.45							Fee Schedule		25.45							Fee Schedule		97.34							Fee Schedule		29.27							Fee Schedule		23.67							Fee Schedule		25.45							Fee Schedule		29.27							Fee Schedule		23.67							Fee Schedule		
B2 GLYCOPROTEIN I AB IGM 36553 RT	300	RC	86146	CPT				Both			108.15	48.67	22.62	97.34	22.62							Fee Schedule		28.28							Fee Schedule		26.21							Fee Schedule		25.45							Fee Schedule		25.45							Fee Schedule		97.34							Fee Schedule		29.27							Fee Schedule		23.67							Fee Schedule		25.45							Fee Schedule		29.27							Fee Schedule		23.67							Fee Schedule		
BA SWALLOW ESOPHAGUS	320	RC	74220	CPT				Both			315	141.75	33.33	318	53.44							Fee Schedule		57.34							Fee Schedule											33.33							Fee Schedule											283.5							Fee Schedule																				318							Per Diem																				
BA SWALLOW ESOPHAGUS WITH AIR	320	RC	74221	CPT				Both			315	141.75	54.33	318	59.99							Fee Schedule		66.87							Fee Schedule											54.33							Fee Schedule											283.5							Fee Schedule																				318							Per Diem																				
BACID CAP	250	RC	A9270	CPT				Both			4.2	1.89	0.01	3.78	0.01							Fee Schedule		3.11							Fee Schedule																													3.78							Fee Schedule																																															
"BACITRACIN 50,000 UNIT VIAL"	250	RC						Both			40.95	18.43	18.43	36.86	26.62							Fee Schedule		30.3							Fee Schedule																													36.86							Fee Schedule																																															
BACITRACIN 500 UNITS/GM OPTHL OINT-3.5GM	250	RC	A9270	CPT				Both			13.48	6.07	0.01	12.13	0.01							Fee Schedule		9.98							Fee Schedule																													12.13							Fee Schedule																																															
BACITRACIN OINT 30 GMS	250	RC	A9270	CPT				Both			8	3.6	0.01	7.2	0.01							Fee Schedule		5.92							Fee Schedule																													7.2							Fee Schedule																																															
BACITRACIN OINT UD PACKETS	250	RC	A9270	CPT				Both			3	1.35	0.01	2.7	0.01							Fee Schedule		2.22							Fee Schedule																													2.7							Fee Schedule																																															
BACLOFEN 10 MG TABLET	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
BACLOFEN 10 MG TABLET UD	250	RC	A9270	CPT				Both			1.58	0.71	0.01	1.42	0.01							Fee Schedule		1.17							Fee Schedule																													1.42							Fee Schedule																																															
BACLOFEN 20 MG TABLET	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
BACTERIAL MENINGITIS AG PANEL 34084	300	RC						Both			1.05	0.47	0.47	0.95	0.68							Fee Schedule		0.78							Fee Schedule																													0.95							Fee Schedule																																															
BACTERIAL VAGINOSIS PANEL 14577 (ATTS)	306	RC	87510	CPT				Both			115.5	51.98	17.83	103.95	17.83							Fee Schedule		22.28							Fee Schedule		20.65							Fee Schedule		20.05							Fee Schedule		20.05							Fee Schedule		103.95							Fee Schedule		23.06							Fee Schedule		18.65							Fee Schedule		20.05							Fee Schedule		23.06							Fee Schedule		18.65							Fee Schedule		
BAG-IT SPONGE COUNTER # 31144119	270	RC						Both			1.42	0.64	0.64	1.28	0.92							Fee Schedule		1.05							Fee Schedule																													1.28							Fee Schedule																																															
BAIR HUGGER BLANKET FULL BODY #40034	271	RC						Both			13	5.85	5.85	11.7	8.45							Fee Schedule		9.62							Fee Schedule																													11.7							Fee Schedule																																															
BAIR HUGGER BLANKET LOW BODY #42568	271	RC						Both			35	15.75	15.75	31.5	22.75							Fee Schedule		25.9							Fee Schedule																													31.5							Fee Schedule																																															
BAIR HUGGER BLANKET LOWER BODY #52500	271	RC						Both			23.1	10.4	10.4	20.79	15.02							Fee Schedule		17.09							Fee Schedule																													20.79							Fee Schedule																																															
BAIR HUGGER BLANKET UNDER BODY #54500	271	RC						Both			46	20.7	20.7	41.4	29.9							Fee Schedule		34.04							Fee Schedule																													41.4							Fee Schedule																																															
BAIR HUGGER BLANKET UPP BODY #42234	271	RC						Both			15	6.75	6.75	13.5	9.75							Fee Schedule		11.1							Fee Schedule																													13.5							Fee Schedule																																															
BAIR HUGGER BLOOD WARMING SET #24200	271	RC						Both			27	12.15	12.15	24.3	17.55							Fee Schedule		19.98							Fee Schedule																													24.3							Fee Schedule																																															
BAIR PAWS FLEX BLANKET #81003	271	RC						Both			39	17.55	17.55	35.1	25.35							Fee Schedule		28.86							Fee Schedule																													35.1							Fee Schedule																																															
BAKRI POSTPARTUM BALLOON # G24237	272	RC	C2628	CPT				Both			765.45	344.45	203.48	688.91	203.48							Fee Schedule		566.43							Fee Schedule																													688.91							Fee Schedule																																															
BAL OIL 100 MG/ML-3ML AMPULE	636	RC	J0470	CPT				Both			96.47	43.41	14.15	86.82		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	71.39							Fee Schedule											14.15							Fee Schedule											86.82							Fee Schedule																																															
BALL SPLINT MASON ALLEN LARGE	270	RC						Both			84	37.8	37.8	75.6	54.6							Fee Schedule		62.16							Fee Schedule																													75.6							Fee Schedule																																															
BALL SPLINT MASON ALLEN MEDIUM	274	RC	A4570	CPT				Both			84	37.8	17.85	75.6		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	62.16							Fee Schedule											17.85							Fee Schedule											75.6							Fee Schedule																																															
BALL SPLINT MASON ALLEN SMALL	274	RC	A4570	CPT				Both			84	37.8	17.85	75.6		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	62.16							Fee Schedule											17.85							Fee Schedule											75.6							Fee Schedule																																															
BALLOON PRESS. AMS800 SPHINCTER 72400024	278	RC	C1815	CPT				Both			11190	5035.5	5035.5	10071		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	8280.6							Fee Schedule																													10071							Fee Schedule																																															
BALSALAZIDE 750 MG CAPSULE	250	RC	A9270	CPT				Both			5.25	2.36	0.01	4.73	0.01							Fee Schedule		3.89							Fee Schedule																													4.73							Fee Schedule																																															
BANANA BAG	250	RC	A9270	CPT				Both			157.5	70.88	0.01	141.75	0.01							Fee Schedule		116.55							Fee Schedule																													141.75							Fee Schedule																																															
BARALYME 8003138	270	RC						Both			44.1	19.85	19.85	39.69	28.67							Fee Schedule		32.63							Fee Schedule																													39.69							Fee Schedule																																															
BARD BIO NDL 18X16	272	RC						Both			118.65	53.39	53.39	106.79	77.12							Fee Schedule		87.8							Fee Schedule																													106.79							Fee Schedule																																															
BARD BOLUS DEVICE #000259 (BARD ACCESS)	272	RC						Both			23.1	10.4	10.4	20.79	15.02							Fee Schedule		17.09							Fee Schedule																													20.79							Fee Schedule																																															
BARD BUTTON DEVICE FEED TUBE 18FR 3.4CM	272	RC						Both			449.4	202.23	202.23	404.46	292.11							Fee Schedule		332.56							Fee Schedule																													404.46							Fee Schedule																																															
BARD BUTTON DEVICE FEED TUBE 24 FR. #000	272	RC						Both			34.65	15.59	15.59	31.19	22.52							Fee Schedule		25.64							Fee Schedule																													31.19							Fee Schedule																																															
BARD BUTTON DEVICE FEED TUBE 24FR 3.4CM	272	RC						Both			534.45	240.5	240.5	481.01	347.39							Fee Schedule		395.49							Fee Schedule																													481.01							Fee Schedule																																															
BARD CLOSED WOUND SUCT. KIT 0043610	272	RC						Both			25.73	11.58	11.58	23.16	16.72							Fee Schedule		19.04							Fee Schedule																													23.16							Fee Schedule																																															
BARD COAGULATING RESECTOR #355211	272	RC						Both			484.05	217.82	217.82	435.65	314.63							Fee Schedule		358.2							Fee Schedule																													435.65							Fee Schedule																																															
BARD CORE BIOPSY KIT    2016MSK (PERIPH)	272	RC						Both			168	75.6	75.6	151.2	109.2							Fee Schedule		124.32							Fee Schedule																													151.2							Fee Schedule																																															
BARD CORE BIOPSY KIT 1810MSK  PERPH	272	RC						Both			168	75.6	75.6	151.2	109.2							Fee Schedule		124.32							Fee Schedule																													151.2							Fee Schedule																																															
BARD CORE BIOPSY KIT 1820MSK (PERIPH)	272	RC						Both			168	75.6	75.6	151.2	109.2							Fee Schedule		124.32							Fee Schedule																													151.2							Fee Schedule																																															
BARD CORE BIOPSY KIT 20G 20	272	RC						Both			168	75.6	75.6	151.2	109.2							Fee Schedule		124.32							Fee Schedule																													151.2							Fee Schedule																																															
BARD FILLAFORM CATH.  021905	272	RC						Both			197.4	88.83	88.83	177.66	128.31							Fee Schedule		146.08							Fee Schedule																													177.66							Fee Schedule																																															
BARD FILLFORM CATH.021904	272	RC						Both			197.4	88.83	88.83	177.66	128.31							Fee Schedule		146.08							Fee Schedule																													177.66							Fee Schedule																																															
BARD G-BUTTON 24FR. 1.7 # 000285	272	RC						Both			449.4	202.23	202.23	404.46	292.11							Fee Schedule		332.56							Fee Schedule																													404.46							Fee Schedule																																															
BARD G-TUBE ASSEMBLY 18 FR. #000282	272	RC						Both			449.4	202.23	202.23	404.46	292.11							Fee Schedule		332.56							Fee Schedule																													404.46							Fee Schedule																																															
BARD G-TUBE ASSEMBLY 18 FR. #000283	272	RC						Both			393.75	177.19	177.19	354.38	255.94							Fee Schedule		291.38							Fee Schedule																													354.38							Fee Schedule																																															
BARD G-TUBE ASSEMBLY 18 FR. #000284	272	RC						Both			393.75	177.19	177.19	354.38	255.94							Fee Schedule		291.38							Fee Schedule																													354.38							Fee Schedule																																															
BARD G-TUBE ASSEMBLY 18 FR. #000292	272	RC						Both			393.75	177.19	177.19	354.38	255.94							Fee Schedule		291.38							Fee Schedule																													354.38							Fee Schedule																																															
BARD HERNIA PATCH 5950007 DAVOL	278	RC	C1781	CPT				Both			1197	538.65	538.65	1077.3		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	885.78							Fee Schedule																													1077.3							Fee Schedule																																															
BARD HERNIA PATCH 5950008 DAVOL	278	RC	C1781	CPT				Both			1464	658.8	658.8	1317.6		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1083.36							Fee Schedule																													1317.6							Fee Schedule																																															
BARD HERNIA PATCH 5950009 DAVOL	278	RC	C1781	CPT				Both			1950	877.5	877.5	1755		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1443							Fee Schedule																													1755							Fee Schedule																																															
BARD HERNIA STAPLER CAPSURE 15 (0113215)	272	RC						Both			787.5	354.38	354.38	708.75	511.88							Fee Schedule		582.75							Fee Schedule																													708.75							Fee Schedule																																															
BARD HERNIA STAPLER CAPSURE 30 0113230	272	RC						Both			840	378	378	756	546							Fee Schedule		621.6							Fee Schedule																													756							Fee Schedule																																															
BARD MAX LIGHT MESH 0117311 DAVOL	278	RC	C1781	CPT				Both			595.35	267.91	267.91	535.82		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	440.56							Fee Schedule																													535.82							Fee Schedule																																															
BARD MAX LIGHT MESH 0117311 DAVOL	278	RC	C1781	CPT				Both			663.6	298.62	298.62	597.24		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	491.06							Fee Schedule																													597.24							Fee Schedule																																															
BARD MESH 3D MAX LEFT LG 0115311 DAVOL	278	RC	C1781	CPT				Both			541	243.45	243.45	486.9		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	400.34							Fee Schedule																													486.9							Fee Schedule																																															
BARD MESH 3D MAX RIGHT LG 0115321 DAVOL	278	RC	C1781	CPT				Both			541	243.45	243.45	486.9		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	400.34							Fee Schedule																													486.9							Fee Schedule																																															
BARD MESH 5950007 (DAVOL)	278	RC	C1781	CPT				Both			1197	538.65	538.65	1077.3		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	885.78							Fee Schedule																													1077.3							Fee Schedule																																															
BARD MESH 5950008 (DAVOL)	278	RC	C1781	CPT				Both			1435	645.75	645.75	1291.5		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1061.9							Fee Schedule																													1291.5							Fee Schedule																																															
BARD MESH 5950009 (DAVOL)	278	RC	C1781	CPT				Both			1920	864	864	1728		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1420.8							Fee Schedule																													1728							Fee Schedule																																															
BARD MESH ECHO 5955600  DAVOL	278	RC	C1781	CPT				Both			2696	1213.2	1213.2	2426.4		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1995.04							Fee Schedule																													2426.4							Fee Schedule																																															
BARD MESH ECHO 5955800  DAVOL	278	RC	C1781	CPT				Both			4500	2025	2025	4050		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	3330							Fee Schedule																													4050							Fee Schedule																																															
BARD MESH ECHO 5955810  DAVOL	278	RC	C1781	CPT				Both			5588	2514.6	2514.6	5029.2		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	4135.12							Fee Schedule																													5029.2							Fee Schedule																																															
BARD PERFIX PLUG LARGE # 0112770 DAVOL	278	RC	C1781	CPT				Both			441	198.45	198.45	396.9		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	326.34							Fee Schedule																													396.9							Fee Schedule																																															
BARD PERFIX PLUG MESH  0112760 DAVOL	278	RC	C1781	CPT				Both			450	202.5	202.5	405		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	333							Fee Schedule																													405							Fee Schedule																																															
BARD PERFIX PLUG MESH  0112780 DAVOL	278	RC	C1781	CPT				Both			514.5	231.53	231.53	463.05		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	380.73							Fee Schedule																													463.05							Fee Schedule																																															
BARD PERFIX PLUG MESH  0112980 DAVOL	278	RC	C1781	CPT				Both			519	233.55	233.55	467.1		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	384.06							Fee Schedule																													467.1							Fee Schedule																																															
BARD PERFIX PLUG XL 0112980 DAVOL	278	RC	C1781	CPT				Both			519	233.55	233.55	467.1		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	384.06							Fee Schedule																													467.1							Fee Schedule																																															
BARD SOFT MESH 0117011 DAVOL	278	RC	C1781	CPT				Both			426	191.7	191.7	383.4		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	315.24							Fee Schedule																													383.4							Fee Schedule																																															
BARD URETHRAL STENT  090630SL	272	RC						Both			446.25	200.81	200.81	401.63	290.06							Fee Schedule		330.23							Fee Schedule																													401.63							Fee Schedule																																															
BARD VENTRALEX PATCH 0010301	278	RC	C1781	CPT				Both			1247.4	561.33	561.33	1122.66		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	923.08							Fee Schedule																													1122.66							Fee Schedule																																															
BARD XENMATRIX 1150808	278	RC	C9356	CPT				Both			4826	2171.7	2171.7	4343.4		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	3571.24							Fee Schedule																													4343.4							Fee Schedule																																															
BARDEX 2-WAY COUDE-TIP 0102SI12 (BD MED)	272	RC						Both			44	19.8	19.8	39.6	28.6							Fee Schedule		32.56							Fee Schedule																													39.6							Fee Schedule																																															
BARDEX 2-WAY COUDE-TIP 0102SI18 (BD MED)	272	RC						Both			44	19.8	19.8	39.6	28.6							Fee Schedule		32.56							Fee Schedule																													39.6							Fee Schedule																																															
BARDEX 2-WAY COUDE-TIP 0102SI22 (BD MED)	272	RC						Both			44	19.8	19.8	39.6	28.6							Fee Schedule		32.56							Fee Schedule																													39.6							Fee Schedule																																															
BARDIA FOLEY CATHETER 14FR #123514CE	272	RC						Both			21	9.45	9.45	18.9	13.65							Fee Schedule		15.54							Fee Schedule																													18.9							Fee Schedule																																															
BARDIA FOLEY CATHETER 16FR #123516CE	272	RC						Both			21	9.45	9.45	18.9	13.65							Fee Schedule		15.54							Fee Schedule																													18.9							Fee Schedule																																															
BARDIA FOLEY CATHETER 18FR #123518CE	272	RC						Both			21	9.45	9.45	18.9	13.65							Fee Schedule		15.54							Fee Schedule																													18.9							Fee Schedule																																															
BARDIA FOLEY CATHETER 20FR #123520CE	272	RC						Both			21	9.45	9.45	18.9	13.65							Fee Schedule		15.54							Fee Schedule																													18.9							Fee Schedule																																															
BARDIA FOLEY CATHETER 22FR #123522CE	272	RC						Both			21	9.45	9.45	18.9	13.65							Fee Schedule		15.54							Fee Schedule																													18.9							Fee Schedule																																															
BARREL ABRADOR BURR 2.9MM #72201520	272	RC						Both			162.75	73.24	73.24	146.48	105.79							Fee Schedule		120.44							Fee Schedule																													146.48							Fee Schedule																																															
BARTHOLIN GLAND CATHETER 100	272	RC	56420	CPT				Both			64.05	28.82	28.82	116.19	116.19							Fee Schedule		47.4							Fee Schedule																													57.65							Fee Schedule																																															
BARTONELLA AB 37671   2ML SERUM	300	RC	86611	CPT				Both			325.5	146.48	9.04	292.95	9.04							Fee Schedule		11.31							Fee Schedule		10.49							Fee Schedule		10.18							Fee Schedule		10.18							Fee Schedule		292.95							Fee Schedule		11.71							Fee Schedule		9.47							Fee Schedule		10.18							Fee Schedule		11.71							Fee Schedule		9.47							Fee Schedule		
BASIC METABOLIC BMP PANEL	301	RC	80048	CPT				Both			165.9	74.66	7.52	149.31	7.52							Fee Schedule		9.4							Fee Schedule		8.71							Fee Schedule		8.46							Fee Schedule		8.46							Fee Schedule		149.31							Fee Schedule		9.73							Fee Schedule		7.87							Fee Schedule		8.46							Fee Schedule		9.73							Fee Schedule		7.87							Fee Schedule		
BASIC PACK MEDLINE #DYNJP1010	270	RC						Both			12	5.4	5.4	10.8	7.8							Fee Schedule		8.88							Fee Schedule																													10.8							Fee Schedule																																															
BAXTER BREATH.CIRCUIT 2 LITER #2L3712	270	RC						Both			4.2	1.89	1.89	3.78	2.73							Fee Schedule		3.11							Fee Schedule																													3.78							Fee Schedule																																															
BAXTER BREATH.CIRCUIT 3 LITER #2L3922	270	RC						Both			17.85	8.03	8.03	16.07	11.6							Fee Schedule		13.21							Fee Schedule																													16.07							Fee Schedule																																															
BAXTER SET UP PACK	272	RC						Both			16.8	7.56	7.56	15.12	10.92							Fee Schedule		12.43							Fee Schedule																													15.12							Fee Schedule																																															
BBG NASAL ASPIRATOR NEOTECH #N225 BIMECO	272	RC						Both			6	2.7	2.7	5.4	3.9							Fee Schedule		4.44							Fee Schedule																													5.4							Fee Schedule																																															
BCR ABL GENE REARRANGEMENT QN PCR LAV TU	310	RC	81206	CPT				Both			782.25	352.01	145.74	704.03	145.74							Fee Schedule		182.18							Fee Schedule		168.88							Fee Schedule		163.96							Fee Schedule		163.96							Fee Schedule		704.03							Fee Schedule		188.55							Fee Schedule		152.48							Fee Schedule											188.55							Fee Schedule		152.48							Fee Schedule		
"BCRA PANEL (BRCA1,BRCA2) 91863"	310	RC	81162	CPT				Both			4300	1935	1622.11	3870	1622.11							Fee Schedule		2027.64							Fee Schedule		1879.63							Fee Schedule		1824.88							Fee Schedule		1824.88							Fee Schedule		3870							Fee Schedule		2098.61							Fee Schedule		1697.14							Fee Schedule											2098.61							Fee Schedule		1697.14							Fee Schedule		
BD FOLEY CATHETER TRAY 14FR #A902414	272	RC	A4315	CPT				Both			57	25.65	23.75	51.3	23.75							Fee Schedule		42.18							Fee Schedule		38.72							Fee Schedule		29.69							Fee Schedule		37.59							Fee Schedule		51.3							Fee Schedule		43.23							Fee Schedule		34.96							Fee Schedule											43.23							Fee Schedule		34.96							Fee Schedule		
BD FOLEY CATHETER TRAY 16FR #A902416	272	RC	A4315	CPT				Both			57	25.65	23.75	51.3	23.75							Fee Schedule		42.18							Fee Schedule		38.72							Fee Schedule		29.69							Fee Schedule		37.59							Fee Schedule		51.3							Fee Schedule		43.23							Fee Schedule		34.96							Fee Schedule											43.23							Fee Schedule		34.96							Fee Schedule		
BD OPTIMA PROTECTOR P20-O 515064	272	RC						Both			15	6.75	6.75	13.5	9.75							Fee Schedule		11.1							Fee Schedule																													13.5							Fee Schedule																																															
BD URETHRAL TRAY 15FR #INTL15	272	RC	A4351	CPT				Both			19	8.55	1.38	17.1	1.38							Fee Schedule		14.06							Fee Schedule		2.26							Fee Schedule		1.73							Fee Schedule		2.19							Fee Schedule		17.1							Fee Schedule		2.52							Fee Schedule		2.04							Fee Schedule											2.52							Fee Schedule		2.04							Fee Schedule		
BD URINARY DRAINAGE BAG #154002	272	RC	A4357	CPT				Both			9	4.05	4.05	13.52	7.43							Fee Schedule		6.66							Fee Schedule		12.11							Fee Schedule		9.29							Fee Schedule		11.76							Fee Schedule		8.1							Fee Schedule		13.52							Fee Schedule		10.94							Fee Schedule											13.52							Fee Schedule		10.94							Fee Schedule		
BD VERITOR FLU A & B TESTS B256045	270	RC						Both			35	15.75	15.75	31.5	22.75							Fee Schedule		25.9							Fee Schedule																													31.5							Fee Schedule																																															
BE	320	RC	74270	CPT				Both			451.5	203.18	48.22	406.35	94.78							Fee Schedule		115.46							Fee Schedule											48.22							Fee Schedule											406.35							Fee Schedule																				318							Per Diem																				
BE W AIR	320	RC	74280	CPT				Both			619.5	278.78	63.28	557.55	134.08							Fee Schedule		162.22							Fee Schedule											63.28							Fee Schedule											557.55							Fee Schedule																				318							Per Diem																				
BEACH BOY CAST BOOT L 79-81077	274	RC	A4565	CPT				Both			17.85	8.03	8.03	16.07		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	13.21							Fee Schedule		11.31							Fee Schedule		8.66							Fee Schedule		10.98							Fee Schedule		16.07							Fee Schedule		12.63							Fee Schedule		10.21							Fee Schedule											12.63							Fee Schedule		10.21							Fee Schedule		
BEACH BOY CAST BOOT M 79-81075	274	RC	A4565	CPT				Both			17.85	8.03	8.03	16.07		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	13.21							Fee Schedule		11.31							Fee Schedule		8.66							Fee Schedule		10.98							Fee Schedule		16.07							Fee Schedule		12.63							Fee Schedule		10.21							Fee Schedule											12.63							Fee Schedule		10.21							Fee Schedule		
BEACH BOY CAST BOOT S 79-81073	274	RC	A4565	CPT				Both			17.85	8.03	8.03	16.07		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	13.21							Fee Schedule		11.31							Fee Schedule		8.66							Fee Schedule		10.98							Fee Schedule		16.07							Fee Schedule		12.63							Fee Schedule		10.21							Fee Schedule											12.63							Fee Schedule		10.21							Fee Schedule		
BEAVER BLADE DEBAKEY # 374810	272	RC						Both			16.28	7.33	7.33	14.65	10.58							Fee Schedule		12.05							Fee Schedule																													14.65							Fee Schedule																																															
BECONASE 42MCG MD INHALER- 16.8GM	636	RC	J3535	CPT				Both			180.08	81.04	81.04	162.07		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	133.26							Fee Schedule																													162.07							Fee Schedule																																															
BECONASE AQ 42MCG NASAL SPRAY-25GM	636	RC						Both			476.34	214.35	214.35	428.71		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	352.49							Fee Schedule																													428.71							Fee Schedule																																															
BECONASE INHALER 16.8 G	636	RC	J3535	CPT				Both			138.35	62.26	62.26	124.52		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	102.38							Fee Schedule																													124.52							Fee Schedule																																															
BED OF NAILS	278	RC						Both			266.7	120.02	120.02	240.03		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	197.36							Fee Schedule																													240.03							Fee Schedule																																															
BEDPAN BARIATRIC 900LB. #DYNC8552	271	RC	E0275	CPT				Both			12	5.4	5.4	19.61	9.32							Fee Schedule		8.88							Fee Schedule		17.56							Fee Schedule											17.05							Fee Schedule		10.8							Fee Schedule		19.61							Fee Schedule		15.86							Fee Schedule											19.61							Fee Schedule		15.86							Fee Schedule		
BEDPAN STACKABLE #DYND80245	271	RC	E0275	CPT				Both			2	0.9	0.9	19.61	9.32							Fee Schedule		1.48							Fee Schedule		17.56							Fee Schedule											17.05							Fee Schedule		1.8							Fee Schedule		19.61							Fee Schedule		15.86							Fee Schedule											19.61							Fee Schedule		15.86							Fee Schedule		
BELLADONNA ALKALOIDS W/ PHENOBARB ELIX	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
BELLADONNA/OPIUM RECTAL SUPP 16.2MG-60MG	636	RC	J3490	CPT				Both			100.35	45.16	45.16	90.32		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	74.26							Fee Schedule																													90.32							Fee Schedule																																															
BENAZEPRIL  5 MG (LOTENSIN) TABLET	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
BENAZEPRIL 10 MG (LOTENSIN) TABLET	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
BENAZEPRIL 20 MG (LOTENSIN) TABLET	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
BENAZEPRIL 40 MG (LOTENSIN) TABLET	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
BENEPROTEIN NUTRITIONAL SUPPLEMENT PACK	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
BENESTA PLUS W/OUTFLOW TUBING CAL-TR1721	272	RC						Both			2517	1132.65	1132.65	2265.3	1636.05							Fee Schedule		1862.58							Fee Schedule																													2265.3							Fee Schedule																																															
BENGAY GREASELESS CREAM- 60GRAM	250	RC	A9270	CPT				Both			12.6	5.67	0.01	11.34	0.01							Fee Schedule		9.32							Fee Schedule																													11.34							Fee Schedule																																															
"BENZODIAZEPINES, SERUM 70071"	301	RC	80346	CPT				Both			193.65	87.14	0.01	174.29	0.01							Fee Schedule									Other	No Additional Reimbursement 																												174.29							Fee Schedule																																															
BENZOIN AMPULES #C1544	270	RC						Both			1.05	0.47	0.47	0.95	0.68							Fee Schedule		0.78							Fee Schedule																													0.95							Fee Schedule																																															
BENZOIN TINC COMPOUND-2OZ	250	RC	A9270	CPT				Both			30.45	13.7	0.01	27.41	0.01							Fee Schedule		22.53							Fee Schedule																													27.41							Fee Schedule																																															
BENZONATATE 100 MG (TESSALON) PERLES	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
BENZTROPINE 1 MG (COGENTIN) TABLET	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
BENZTROPINE 1 MG/ML- 2 ML AMP (COGENTIN)	636	RC	J0515	CPT				Both			236.25	106.31	7.71	212.63		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	174.83							Fee Schedule		13.94							Fee Schedule		7.71							Fee Schedule		13.54							Fee Schedule		212.63							Fee Schedule		15.57							Fee Schedule		12.59							Fee Schedule											15.57							Fee Schedule		12.59							Fee Schedule		
BENZTROPINE 6055 SERUM COGENTIN	301	RC	80299	CPT				Both			165.9	74.66	13.42	149.31	13.42							Fee Schedule		18.64							Fee Schedule		19.2							Fee Schedule		18.64							Fee Schedule		18.64							Fee Schedule		149.31							Fee Schedule		21.44							Fee Schedule		17.34							Fee Schedule		18.64							Fee Schedule		21.44							Fee Schedule		17.34							Fee Schedule		
BERMAN BREAKAWAY AIRWAY SZ8 SH36029	271	RC						Both			22.05	9.92	9.92	19.85	14.33							Fee Schedule		16.32							Fee Schedule																													19.85							Fee Schedule																																															
BERYLLIUM 7131  4ML SERUM ROOM TEMP	300	RC	83018	CPT				Both			159.6	71.82	19.53	143.64	19.53							Fee Schedule		24.41							Fee Schedule		22.62							Fee Schedule		21.96							Fee Schedule		21.96							Fee Schedule		143.64							Fee Schedule		25.25							Fee Schedule		20.42							Fee Schedule		21.96							Fee Schedule		25.25							Fee Schedule		20.42							Fee Schedule		
BETA 2 MICROGLOB 852 SERUM	301	RC	82232	CPT				Both			191.1	86	14.38	171.99	14.38							Fee Schedule		17.97							Fee Schedule		16.67							Fee Schedule		16.18							Fee Schedule		16.18							Fee Schedule		171.99							Fee Schedule		18.61							Fee Schedule		15.05							Fee Schedule		16.18							Fee Schedule		18.61							Fee Schedule		15.05							Fee Schedule		
BETA 2 TRANSFER 10640 BODY FLUID	302	RC	86334	CPT				Both			256.2	115.29	19.86	230.58	19.86							Fee Schedule		24.83							Fee Schedule		23.01							Fee Schedule		22.34							Fee Schedule		22.34							Fee Schedule		230.58							Fee Schedule		25.69							Fee Schedule		20.78							Fee Schedule		22.34							Fee Schedule		25.69							Fee Schedule		20.78							Fee Schedule		
BETA HYDROXY OH BYTYRATE 37054 SERUM FRZ	301	RC	84311	CPT				Both			191.1	86	6.21	171.99	6.21							Fee Schedule		8.1							Fee Schedule		8.34							Fee Schedule		8.1							Fee Schedule		8.1							Fee Schedule		171.99							Fee Schedule		9.32							Fee Schedule		7.53							Fee Schedule		8.1							Fee Schedule		9.32							Fee Schedule		7.53							Fee Schedule		
BETA STREP GROUP A SOFIA	300	RC	87430	CPT				Both			102.9	46.31	12.1	92.61	12.1							Fee Schedule		16.81							Fee Schedule		17.31							Fee Schedule		16.81							Fee Schedule		16.81							Fee Schedule		92.61							Fee Schedule		19.33							Fee Schedule		15.63							Fee Schedule		16.81							Fee Schedule		19.33							Fee Schedule		15.63							Fee Schedule		
BETADINE EZ SCRUB 371073	272	RC	A4248	CPT				Both			2	0.9	0.9	1.8	1.25							Fee Schedule		1.48							Fee Schedule																													1.8							Fee Schedule																																															
BETADINE PERI WASH MDS093943  MEDLINE	272	RC						Both			11.5	5.18	5.18	10.35	7.48							Fee Schedule		8.51							Fee Schedule																													10.35							Fee Schedule																																															
BETADINE SCRUB BRUSH #372053	272	RC						Both			2	0.9	0.9	1.8	1.3							Fee Schedule		1.48							Fee Schedule																													1.8							Fee Schedule																																															
BETADINE V GAUZE	250	RC	A9270	CPT				Both			4.2	1.89	0.01	3.78	0.01							Fee Schedule		3.11							Fee Schedule																													3.78							Fee Schedule																																															
BETAM SOD/ BETA AC 6MG/ML-MDV(CELESTONE)	636	RC	J0702	CPT				Both			141.75	63.79	5.19	127.58		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	104.9							Fee Schedule		7.34							Fee Schedule		5.19							Fee Schedule		7.13							Fee Schedule		127.58							Fee Schedule		8.19							Fee Schedule		6.63							Fee Schedule											8.19							Fee Schedule		6.63							Fee Schedule		
BETAMETHASONE VALERATE 0.1% CREAM-15GM	250	RC	A9270	CPT				Both			88.2	39.69	0.01	79.38	0.01							Fee Schedule		65.27							Fee Schedule																													79.38							Fee Schedule																																															
BETAMETHASONE VALERATE 0.1% OINT-15GM	250	RC	A9270	CPT				Both			11.18	5.03	0.01	10.06	0.01							Fee Schedule		8.27							Fee Schedule																													10.06							Fee Schedule																																															
BETAMETHASONE VALERATE LOTION	250	RC	A9270	CPT				Both			36.75	16.54	0.01	33.08	0.01							Fee Schedule		27.2							Fee Schedule																													33.08							Fee Schedule																																															
BETHANECHOL 25 MG (URECHOLINE) TABLET	250	RC	A9270	CPT				Both			8.4	3.78	0.01	7.56	0.01							Fee Schedule		6.22							Fee Schedule																													7.56							Fee Schedule																																															
BETOPIC OPTH SOL	250	RC	A9270	CPT				Both			51.19	23.04	0.01	46.07	0.01							Fee Schedule		37.88							Fee Schedule																													46.07							Fee Schedule																																															
BETOPTIC-S 0.25% OPTH SOLUTION-10 ML	250	RC	A9270	CPT				Both			1173.9	528.26	0.01	1056.51	0.01							Fee Schedule		868.69							Fee Schedule																													1056.51							Fee Schedule																																															
BEXSERO MENINGOCOCCAL 0.5ML VACCINE	636	RC	90620	CPT				Both			178.5	80.33	80.33	160.65		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	132.09							Fee Schedule																													160.65							Fee Schedule																																															
BEXTRA 10 MG TABL0T UD	250	RC	A9270	CPT				Both			10.5	4.73	0.01	9.45	0.01							Fee Schedule		7.77							Fee Schedule																													9.45							Fee Schedule																																															
BEYFORTUS 100MG/ML SYRINGE	636	RC	90381	CPT				Both			1871.1	842	842	1683.99		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1384.61							Fee Schedule																													1683.99							Fee Schedule																																															
BEYFORTUS 50MG/0.5ML SYRINGE	636	RC	90380	CPT				Both			1782	801.9	801.9	1603.8		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1318.68							Fee Schedule																													1603.8							Fee Schedule																																															
BHCG QUANT 8396 TO REF LAB SERUM 1ML	301	RC	84702	CPT				Both			189	85.05	13.38	170.1	13.38							Fee Schedule		16.73							Fee Schedule		15.5							Fee Schedule		15.05							Fee Schedule		15.05							Fee Schedule		170.1							Fee Schedule		17.31							Fee Schedule		14							Fee Schedule		15.05							Fee Schedule		17.31							Fee Schedule		14							Fee Schedule		
BHCG QUANT SERUM PREG TEST IN HOUSE	301	RC	84702	CPT				Both			142.8	64.26	13.38	128.52	13.38							Fee Schedule		16.73							Fee Schedule		15.5							Fee Schedule		15.05							Fee Schedule		15.05							Fee Schedule		128.52							Fee Schedule		17.31							Fee Schedule		14							Fee Schedule		15.05							Fee Schedule		17.31							Fee Schedule		14							Fee Schedule		
BI POLAR HEAD	278	RC	C1776	CPT				Both			2514.75	1131.64	1131.64	2263.28		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1860.92							Fee Schedule																													2263.28							Fee Schedule																																															
BIAXIN 250 MG/5ML ORAL SUSP-50ML	250	RC	A9270	CPT				Both			94.5	42.53	0.01	85.05	0.01							Fee Schedule		69.93							Fee Schedule																													85.05							Fee Schedule																																															
BICAP HEMOSTASIS PRB	272	RC						Both			748.65	336.89	336.89	673.79	486.62							Fee Schedule		554							Fee Schedule																													673.79							Fee Schedule																																															
BICAP TUBING BC-3	272	RC						Both			220.5	99.23	99.23	198.45	143.33							Fee Schedule		163.17							Fee Schedule																													198.45							Fee Schedule																																															
"BICILLIN CR  600,000 UNIT/ML INJ"	636	RC	J0558	CPT				Both			49.09	22.09	18.16	44.18		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	19.53							Fee Schedule		20.11							Fee Schedule											19.52							Fee Schedule		44.18							Fee Schedule		22.45							Fee Schedule		18.16							Fee Schedule											22.45							Fee Schedule		18.16							Fee Schedule		
BICILLIN CR 1.2 MIL UNIT/ML INJ	636	RC	J0558	CPT				Both			136.5	61.43	18.16	122.85		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	19.53							Fee Schedule		20.11							Fee Schedule											19.52							Fee Schedule		122.85							Fee Schedule		22.45							Fee Schedule		18.16							Fee Schedule											22.45							Fee Schedule		18.16							Fee Schedule		
BICILLIN CR 2.4 MIL UNIT/ML INJ	636	RC	J0558	CPT				Both			206.33	92.85	18.16	185.7		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	19.53							Fee Schedule		20.11							Fee Schedule											19.52							Fee Schedule		185.7							Fee Schedule		22.45							Fee Schedule		18.16							Fee Schedule											22.45							Fee Schedule		18.16							Fee Schedule		
"BICILLIN CR 900/300,000 UNIT/ML INJ"	250	RC	J0558	CPT				Both			474.6	213.57	10.87	427.14	10.87							Fee Schedule		19.53							Fee Schedule		20.11							Fee Schedule											19.52							Fee Schedule		427.14							Fee Schedule		22.45							Fee Schedule		18.16							Fee Schedule											22.45							Fee Schedule		18.16							Fee Schedule		
BICILLIN LA 1.2 MUNIT/2ML INJECTION	250	RC	J0561	CPT				Both			595.35	267.91	13.76	535.82	13.76							Fee Schedule		31.46							Fee Schedule		32.92							Fee Schedule											31.97							Fee Schedule		535.82							Fee Schedule		36.76							Fee Schedule		29.73							Fee Schedule											36.76							Fee Schedule		29.73							Fee Schedule		
BICILLIN LA 2.4 MUNIT/4ML INJECTION	636	RC	J0561	CPT				Both			1219.05	548.57	29.73	1097.15		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	31.46							Fee Schedule		32.92							Fee Schedule											31.97							Fee Schedule		1097.15							Fee Schedule		36.76							Fee Schedule		29.73							Fee Schedule											36.76							Fee Schedule		29.73							Fee Schedule		
"BICILLIN LA 600,000 UNIT/ML INJECT"	636	RC	J0561	CPT				Both			343.35	154.51	29.73	309.02		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	31.46							Fee Schedule		32.92							Fee Schedule											31.97							Fee Schedule		309.02							Fee Schedule		36.76							Fee Schedule		29.73							Fee Schedule											36.76							Fee Schedule		29.73							Fee Schedule		
BILE ACIDS FRACTIONATED 19546 1ML SERUM	301	RC	82542	CPT				Both			236.25	106.31	17.34	212.63	17.34							Fee Schedule		24.09							Fee Schedule		24.81							Fee Schedule		24.09							Fee Schedule		24.09							Fee Schedule		212.63							Fee Schedule		27.7							Fee Schedule		22.4							Fee Schedule		24.09							Fee Schedule		27.7							Fee Schedule		22.4							Fee Schedule		
BILE BAGS 19 OZ. 0015850 (BARD MEDICAL)	271	RC						Both			16	7.2	7.2	14.4	10.4							Fee Schedule		11.84							Fee Schedule																													14.4							Fee Schedule																																															
BILI MASK  724302	270	RC						Both			8.4	3.78	3.78	7.56	5.46							Fee Schedule		6.22							Fee Schedule																													7.56							Fee Schedule																																															
BILIARY DRAINAGE STENT # 3204 ( MICROVAS	278	RC	C2617	CPT				Both			168	75.6	75.6	151.2		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	124.32							Fee Schedule																													151.2							Fee Schedule																																															
BILIARY DRAINAGE STENT # 3205 ( MICROVAS	278	RC	C2617	CPT				Both			258.3	116.24	116.24	232.47		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	191.14							Fee Schedule																													232.47							Fee Schedule																																															
BILIARY EVA STENT 10FR PBD-1031-1009	278	RC	C1874	CPT				Both			135.45	60.95	60.95	121.91		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	100.23							Fee Schedule																													121.91							Fee Schedule																																															
BILIARY STENT 10FR MAJ-1820	278	RC	C1874	CPT				Both			205.8	92.61	92.61	185.22		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	152.29							Fee Schedule																													185.22							Fee Schedule																																															
BILIARY STENT CHBSO-8.5-9	278	RC	C1877	CPT				Both			164.85	74.18	74.18	148.37		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	121.99							Fee Schedule																													148.37							Fee Schedule																																															
BILIARY STENT FS-OA-10/G31527 (COOK)	278	RC	C1877	CPT				Both			309	139.05	139.05	278.1		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	228.66							Fee Schedule																													278.1							Fee Schedule																																															
BILICHECK DISP. TIPS #B800-50	270	RC						Both			19	8.55	8.55	17.1	12.35							Fee Schedule		14.06							Fee Schedule																													17.1							Fee Schedule																																															
BILI-LITE PAD COVER SLIP 51499	270	RC						Both			6.3	2.84	2.84	5.67	4.1							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
BILIRUBIN DIRECT	301	RC	82248	CPT				Both			29.4	13.23	4.46	26.46	4.46							Fee Schedule		5.57							Fee Schedule		5.17							Fee Schedule		5.02							Fee Schedule		5.02							Fee Schedule		26.46							Fee Schedule		5.77							Fee Schedule		4.67							Fee Schedule		5.02							Fee Schedule		5.77							Fee Schedule		4.67							Fee Schedule		
BILIRUBIN DIRECT NEONATE	301	RC	82248	CPT				Both			29.4	13.23	4.46	26.46	4.46							Fee Schedule		5.57							Fee Schedule		5.17							Fee Schedule		5.02							Fee Schedule		5.02							Fee Schedule		26.46							Fee Schedule		5.77							Fee Schedule		4.67							Fee Schedule		5.02							Fee Schedule		5.77							Fee Schedule		4.67							Fee Schedule		
BILIRUBIN TOTAL	301	RC	82247	CPT				Both			63	28.35	4.46	56.7	4.46							Fee Schedule		5.57							Fee Schedule		5.17							Fee Schedule		5.02							Fee Schedule		5.02							Fee Schedule		56.7							Fee Schedule		5.77							Fee Schedule		4.67							Fee Schedule		5.02							Fee Schedule		5.77							Fee Schedule		4.67							Fee Schedule		
BILIRUBIN TOTAL NEONATE	301	RC	82247	CPT				Both			36.75	16.54	4.46	33.08	4.46							Fee Schedule		5.57							Fee Schedule		5.17							Fee Schedule		5.02							Fee Schedule		5.02							Fee Schedule		33.08							Fee Schedule		5.77							Fee Schedule		4.67							Fee Schedule		5.02							Fee Schedule		5.77							Fee Schedule		4.67							Fee Schedule		
BINAX NOW COVID-19 TESTS #ALR195000	270	RC						Both			22.05	9.92	9.92	19.85	14.33							Fee Schedule		16.32							Fee Schedule																													19.85							Fee Schedule																																															
BINAX NOW RSV TESTS #R25438	270	RC						Both			36	16.2	16.2	32.4	23.4							Fee Schedule		26.64							Fee Schedule																													32.4							Fee Schedule																																															
BIO DYNA CEMENT PLUG	278	RC						Both			303.45	136.55	136.55	273.11		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	224.55							Fee Schedule																													273.11							Fee Schedule																																															
BIO GLO OPTHL STRIPS	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
BIOCLUSIVE 3X4	272	RC	A6257	CPT				Both			4.2	1.89	1.38	3.78	1.38							Fee Schedule		3.11							Fee Schedule		2.25							Fee Schedule		1.73							Fee Schedule		2.18							Fee Schedule		3.78							Fee Schedule		2.51							Fee Schedule		2.03							Fee Schedule											2.51							Fee Schedule		2.03							Fee Schedule		
BIOCLUSIVE 4X5 #2463  J&J	272	RC	A6258	CPT				Both			5.25	2.36	2.36	7.06	3.88							Fee Schedule		3.89							Fee Schedule		6.32							Fee Schedule		4.85							Fee Schedule		6.14							Fee Schedule		4.73							Fee Schedule		7.06							Fee Schedule		5.71							Fee Schedule											7.06							Fee Schedule		5.71							Fee Schedule		
BIOCLUSIVE 6X8 LARGE	272	RC	A6258	CPT				Both			10.5	4.73	3.88	9.45	3.88							Fee Schedule		7.77							Fee Schedule		6.32							Fee Schedule		4.85							Fee Schedule		6.14							Fee Schedule		9.45							Fee Schedule		7.06							Fee Schedule		5.71							Fee Schedule											7.06							Fee Schedule		5.71							Fee Schedule		
BIOCOL 1G COLLAGEN POWDER #154892	270	RC	A6010	CPT				Both			59	26.55	26.55	53.1	27.89							Fee Schedule		43.66							Fee Schedule		45.46							Fee Schedule											44.14							Fee Schedule		53.1							Fee Schedule		50.76							Fee Schedule		41.05							Fee Schedule											50.76							Fee Schedule		41.05							Fee Schedule		
BIODESIGN 4 LAYER GRAFT  G12580 ( COOK )	278	RC	C1763	CPT				Both			3645	1640.25	1640.25	3280.5		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	2697.3							Fee Schedule																													3280.5							Fee Schedule																																															
BIODESIGN STAPLE LINE REINFORCE G24827	278	RC	C1763	CPT				Both			661.5	297.68	297.68	595.35		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	489.51							Fee Schedule																													595.35							Fee Schedule																																															
BIOINDUCTIVE IMPLANT ARTHRO MED #4565	278	RC						Both			7500	3375	3375	6750		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	5550							Fee Schedule																													6750							Fee Schedule																																															
BIOLOGICAL INTEGRATOR #MDS200567	270	RC						Both			15.75	7.09	7.09	14.18	10.24							Fee Schedule		11.66							Fee Schedule																													14.18							Fee Schedule																																															
BIOLOGICAL TEST PACK T40341PE *DISC*	270	RC						Both			22.05	9.92	9.92	19.85	14.33							Fee Schedule		16.32							Fee Schedule																													19.85							Fee Schedule																																															
BIOMET KNEE LFT. TIBIAL  MEDIAL  154726	278	RC	C1776	CPT				Both			5512.5	2480.63	2480.63	4961.25		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	4079.25							Fee Schedule																													4961.25							Fee Schedule																																															
BIOMET LAT. PART. KNEE  154331	278	RC	C1776	CPT				Both			7459.2	3356.64	3356.64	6713.28		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	5519.81							Fee Schedule																													6713.28							Fee Schedule																																															
BIOMET MENISCAL BEARING  158551	278	RC	C1776	CPT				Both			2992.5	1346.63	1346.63	2693.25		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	2214.45							Fee Schedule																													2693.25							Fee Schedule																																															
BIOMET MENISCAL BEARING KNEE # 159575	278	RC	C1776	CPT				Both			2992.5	1346.63	1346.63	2693.25		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	2214.45							Fee Schedule																													2693.25							Fee Schedule																																															
BIOMET MODULAR RADIAL HEAD 11-210023	278	RC	C1776	CPT				Both			6300	2835	2835	5670		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	4662							Fee Schedule																													5670							Fee Schedule																																															
BIOMET MODULAR RADIAL HEAD 11-210042	278	RC	C1776	CPT				Both			6300	2835	2835	5670		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	4662							Fee Schedule																													5670							Fee Schedule																																															
BIOMET MODULAR RADIAL STEM 11-210062	278	RC	C1776	CPT				Both			6300	2835	2835	5670		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	4662							Fee Schedule																													5670							Fee Schedule																																															
BIOMET OXFORD MENISCAL BEARING 159583	278	RC	C1776	CPT				Both			3625.65	1631.54	1631.54	3263.09		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	2682.98							Fee Schedule																													3263.09							Fee Schedule																																															
BIOMET OXFORD MENISCAL BEARING 159589	278	RC	C1776	CPT				Both			2693.25	1211.96	1211.96	2423.93		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1993.01							Fee Schedule																													2423.93							Fee Schedule																																															
BIOMET OXFORD PARTIAL KNEE 161471	278	RC	C1776	CPT				Both			8977.5	4039.88	4039.88	8079.75		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	6643.35							Fee Schedule																													8079.75							Fee Schedule																																															
BIOMET OXFORD RESECTION 506124	278	RC	C1776	CPT				Both			1726.2	776.79	776.79	1553.58		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1277.39							Fee Schedule																													1553.58							Fee Schedule																																															
BIOMET OXFORD TIBIAL TRAY 154721	278	RC	C1776	CPT				Both			5512.5	2480.63	2480.63	4961.25		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	4079.25							Fee Schedule																													4961.25							Fee Schedule																																															
BIOMET OXFORD TIBIAL TRAY 154725	278	RC	C1776	CPT				Both			7755.3	3489.89	3489.89	6979.77		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	5738.92							Fee Schedule																													6979.77							Fee Schedule																																															
BIOMET PART KNEE BEARING  159554	278	RC	C1776	CPT				Both			2992.5	1346.63	1346.63	2693.25		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	2214.45							Fee Schedule																													2693.25							Fee Schedule																																															
BIOMET PART KNEE FEMORAL  161470	278	RC	C1776	CPT				Both			11478.6	5165.37	5165.37	10330.74		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	8494.16							Fee Schedule																													10330.74							Fee Schedule																																															
BIOMET PARTIAL KNEE 506269	278	RC	C1776	CPT				Both			1260	567	567	1134		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	932.4							Fee Schedule																													1134							Fee Schedule																																															
BIOMET PARTIAL KNEE 506298	278	RC	C1776	CPT				Both			1260	567	567	1134		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	932.4							Fee Schedule																													1134							Fee Schedule																																															
BIOMET RT. MEDIAL TIBIAL TRAY C  154723	278	RC	C1776	CPT				Both			5512.5	2480.63	2480.63	4961.25		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	4079.25							Fee Schedule																													4961.25							Fee Schedule																																															
BIOMET TIBIAL BEARING  183664	278	RC	C1776	CPT				Both			4016.25	1807.31	1807.31	3614.63		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	2972.03							Fee Schedule																													3614.63							Fee Schedule																																															
BIOMET TIBIAL LOCK BAR  141205.	278	RC	C1776	CPT				Both			453.6	204.12	204.12	408.24		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	335.66							Fee Schedule																													408.24							Fee Schedule																																															
BIOMET TIBIAL TRAY 154720	278	RC	C1776	CPT				Both			5512.5	2480.63	2480.63	4961.25		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	4079.25							Fee Schedule																													4961.25							Fee Schedule																																															
BIOMET TIBIAL TRAY KNEE # 154719	278	RC	C1776	CPT				Both			5512.5	2480.63	2480.63	4961.25		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	4079.25							Fee Schedule																													4961.25							Fee Schedule																																															
BIOMET TWIN PEG FEMORAL KNEE #161469	278	RC	C1776	CPT				Both			8190	3685.5	3685.5	7371		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	6060.6							Fee Schedule																													7371							Fee Schedule																																															
BIOOCCLUSIVE TRANS	272	RC						Both			7.35	3.31	3.31	6.62	4.78							Fee Schedule		5.44							Fee Schedule																													6.62							Fee Schedule																																															
BIOPATCH CHG DSG. DISK #AEG017S	272	RC						Both			15	6.75	6.75	13.5	9.75							Fee Schedule		11.1							Fee Schedule																													13.5							Fee Schedule																																															
BIOPLUS ELECTRODE (DO NOT ORDER)	272	RC						Both			13.65	6.14	6.14	12.29	8.87							Fee Schedule		10.1							Fee Schedule																													12.29							Fee Schedule																																															
BIOPSY BLADE MILTEX # 33-100	272	RC						Both			6	2.7	2.7	5.4	3.9							Fee Schedule		4.44							Fee Schedule																													5.4							Fee Schedule																																															
BIOPSY GUN 18GX25CM MC1825 (BD PERIPH)	272	RC						Both			118	53.1	53.1	106.2	76.7							Fee Schedule		87.32							Fee Schedule																													106.2							Fee Schedule																																															
BIOPSY INSTRUMENT MONOPTY PERPH 121820	272	RC						Both			112.35	50.56	50.56	101.12	73.03							Fee Schedule		83.14							Fee Schedule																													101.12							Fee Schedule																																															
BIOPSY NEEDLE TRUE CUT 2N2704X	270	RC						Both			47	21.15	21.15	42.3	30.55							Fee Schedule		34.78							Fee Schedule																													42.3							Fee Schedule																																															
BIOPSY SYSTEM A146	272	RC						Both			93.45	42.05	42.05	84.11	60.74							Fee Schedule		69.15							Fee Schedule																													84.11							Fee Schedule																																															
BIOPSY TRAY SOFT TISSUE 4382SP	272	RC	A4550	CPT				Both			94	42.3	15.31	84.6	15.31							Fee Schedule		69.56							Fee Schedule											36.53							Fee Schedule											84.6							Fee Schedule																																															
BIOPSY VALVE  MAJ-210	272	RC						Both			16	7.2	7.2	14.4	10.4							Fee Schedule		11.84							Fee Schedule																													14.4							Fee Schedule																																															
BIOSTEON ACL SCREW 10MMX23MM 234-010-170	278	RC	C1713	CPT				Both			627.9	282.56	282.56	565.11		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	464.65							Fee Schedule																													565.11							Fee Schedule																																															
BIOSTEON ACL SCREW 10MMX35MM 234-010-178	278	RC	C1713	CPT				Both			627.9	282.56	282.56	565.11		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	464.65							Fee Schedule																													565.11							Fee Schedule																																															
BIOSTEON ACL SCREW 11MMX28MM 234-010-172	278	RC	C1713	CPT				Both			627.9	282.56	282.56	565.11		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	464.65							Fee Schedule																													565.11							Fee Schedule																																															
BIOSTEON ACL SCREW 11MMX35MM 234-010-179	278	RC	C1713	CPT				Both			627.9	282.56	282.56	565.11		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	464.65							Fee Schedule																													565.11							Fee Schedule																																															
BIOSTEON ACL SCREW 12MMX28MM 234-010-173	278	RC	C1713	CPT				Both			627.9	282.56	282.56	565.11		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	464.65							Fee Schedule																													565.11							Fee Schedule																																															
BIOSTEON ACL SCREW 12MMX35MM 234-010-180	278	RC	C1713	CPT				Both			627.9	282.56	282.56	565.11		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	464.65							Fee Schedule																													565.11							Fee Schedule																																															
BIOSTEON ACL SCREW 6MMX23MM 234-010-160	278	RC	C1713	CPT				Both			627.9	282.56	282.56	565.11		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	464.65							Fee Schedule																													565.11							Fee Schedule																																															
BIOSTEON ACL SCREW 6MMX28MM 234-010-168	278	RC	C1713	CPT				Both			627.9	282.56	282.56	565.11		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	464.65							Fee Schedule																													565.11							Fee Schedule																																															
BIOSTEON ACL SCREW 7MMX23MM 234-010-161	278	RC	C1713	CPT				Both			627.9	282.56	282.56	565.11		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	464.65							Fee Schedule																													565.11							Fee Schedule																																															
BIOSTEON ACL SCREW 7MMX28MM 234-010-164	278	RC	C1713	CPT				Both			627.9	282.56	282.56	565.11		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	464.65							Fee Schedule																													565.11							Fee Schedule																																															
BIOSTEON ACL SCREW 9MMX23MM 234-010-163	278	RC	C1713	CPT				Both			741.3	333.59	333.59	667.17		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	548.56							Fee Schedule																													667.17							Fee Schedule																																															
BIOSTEON ACL SCREW 9MMX35MM 234-010-177	278	RC	C1713	CPT				Both			627.9	282.56	282.56	565.11		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	464.65							Fee Schedule																													565.11							Fee Schedule																																															
BIOSTEON SCREW 10MMX28MM 234-010-167	278	RC	C1713	CPT				Both			627.9	282.56	282.56	565.11		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	464.65							Fee Schedule																													565.11							Fee Schedule																																															
BIOSTEON SCREW 8MMX23MM 234-010-162	278	RC	C1713	CPT				Both			741.3	333.59	333.59	667.17		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	548.56							Fee Schedule																													667.17							Fee Schedule																																															
BIOSTEON SCREW 8MMX28MM 234-010-165	278	RC	C1713	CPT				Both			627.9	282.56	282.56	565.11		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	464.65							Fee Schedule																													565.11							Fee Schedule																																															
BIOSTEON SCREW 9MMX28MM 234-010-166	278	RC	C1713	CPT				Both			741.3	333.59	333.59	667.17		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	548.56							Fee Schedule																													667.17							Fee Schedule																																															
BIOSYN 6-0  UM201	272	RC						Both			10.5	4.73	4.73	9.45	6.83							Fee Schedule		7.77							Fee Schedule																													9.45							Fee Schedule																																															
BIOTENE DRY MOUTH ORAL RINSE	250	RC	A9270	CPT				Both			29.46	13.26	0.01	26.51	0.01							Fee Schedule		21.8							Fee Schedule																													26.51							Fee Schedule																																															
BIOTENE GEL 45GM TUBE	250	RC	A9270	CPT				Both			17.85	8.03	0.01	16.07	0.01							Fee Schedule		13.21							Fee Schedule																													16.07							Fee Schedule																																															
BIOTINIDASE 70132	301	RC	82261	CPT				Both			265	119.25	15	238.5	15							Fee Schedule		18.74							Fee Schedule		17.38							Fee Schedule		16.87							Fee Schedule		16.87							Fee Schedule		238.5							Fee Schedule		19.4							Fee Schedule		15.69							Fee Schedule											19.4							Fee Schedule		15.69							Fee Schedule		
BIPAP #582073	270	RC						Both			34.65	15.59	15.59	31.19	22.52							Fee Schedule		25.64							Fee Schedule																													31.19							Fee Schedule																																															
BIPAP CIRCUIT HUD1698	271	RC						Both			18	8.1	8.1	16.2	11.7							Fee Schedule		13.32							Fee Schedule																													16.2							Fee Schedule																																															
BIPAP HEADGEAR #C73-302142	270	RC						Both			112.35	50.56	50.56	101.12	73.03							Fee Schedule		83.14							Fee Schedule																													101.12							Fee Schedule																																															
BIPAP INITIAL	412	RC	94660	CPT				Both			283.5	127.58	48.41	286	175							Per Diem		209.79							Fee Schedule											48.41							Fee Schedule											255.15							Fee Schedule																				286							Case Rate																				
BIPAP MASK LARGE HCSFFNVAL	271	RC						Both			66	29.7	29.7	59.4	42.9							Fee Schedule		48.84							Fee Schedule																													59.4							Fee Schedule																																															
BIPAP MASK MEDIUM #HCSFFNVAM	271	RC						Both			65	29.25	29.25	58.5	42.25							Fee Schedule		48.1							Fee Schedule																													58.5							Fee Schedule																																															
BIPAP MASK PRFMTRK SMALL #HCSFFNVAS	271	RC						Both			66	29.7	29.7	59.4	42.9							Fee Schedule		48.84							Fee Schedule																													59.4							Fee Schedule																																															
BIPOLAR HEMOSTASIS PROBE (CONMED) BP7300	270	RC						Both			537.6	241.92	241.92	483.84	349.44							Fee Schedule		397.82							Fee Schedule																													483.84							Fee Schedule																																															
BISACODYL  5 MG (DULCOLAX) TABLET UD	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
BISACODYL 10 MG (DULCOLAX) RECTAL SUPP	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
BISOPROLOL 5 MG  (ZEBETA) TABLET	250	RC	A9270	CPT				Both			7.35	3.31	0.01	6.62	0.01							Fee Schedule		5.44							Fee Schedule																													6.62							Fee Schedule																																															
BITE STICK #3789	271	RC						Both			2	0.9	0.9	1.8	1.3							Fee Schedule		1.48							Fee Schedule																													1.8							Fee Schedule																																															
BITE STICK EACH	271	RC						Both			2.1	0.95	0.95	1.89	1.37							Fee Schedule		1.55							Fee Schedule																													1.89							Fee Schedule																																															
BK VIRUS DNA QL PCR 11351	300	RC	87798	CPT				Both			189	85.05	31.2	170.1	31.2							Fee Schedule		38.99							Fee Schedule		36.14							Fee Schedule		35.09							Fee Schedule		35.09							Fee Schedule		170.1							Fee Schedule		40.35							Fee Schedule		32.63							Fee Schedule		35.09							Fee Schedule		40.35							Fee Schedule		32.63							Fee Schedule		
"BK VIRUS DNA, PCR, SER 18049"	306	RC	87799	CPT				Both			702	315.9	38.07	631.8	38.07							Fee Schedule		47.6							Fee Schedule		44.13							Fee Schedule		42.84							Fee Schedule		42.84							Fee Schedule		631.8							Fee Schedule		49.27							Fee Schedule		39.84							Fee Schedule		42.84							Fee Schedule		49.27							Fee Schedule		39.84							Fee Schedule		
BLACK SILK 2-0 677G	272	RC						Both			7.35	3.31	3.31	6.62	4.78							Fee Schedule		5.44							Fee Schedule																													6.62							Fee Schedule																																															
BLADE 3.5 CURVED CONCAVE #7210980	272	RC						Both			117	52.65	52.65	105.3	76.05							Fee Schedule		86.58							Fee Schedule																													105.3							Fee Schedule																																															
BLADE 3.5 INCISOR PLUS ELITE #72200095	272	RC						Both			110	49.5	49.5	99	71.5							Fee Schedule		81.4							Fee Schedule																													99							Fee Schedule																																															
BLADE 5.5 BONECUTTER #7206010	272	RC						Both			191	85.95	85.95	171.9	124.15							Fee Schedule		141.34							Fee Schedule																													171.9							Fee Schedule																																															
BLAKE DRAIN #2191  (SENECA)	272	RC						Both			93.45	42.05	42.05	84.11	60.74							Fee Schedule		69.15							Fee Schedule																													84.11							Fee Schedule																																															
BLAKE DRAIN 19 FRENCH 2265	272	RC						Both			128.1	57.65	57.65	115.29	83.27							Fee Schedule		94.79							Fee Schedule																													115.29							Fee Schedule																																															
BLAKE DRAIN 2189	272	RC						Both			118.65	53.39	53.39	106.79	77.12							Fee Schedule		87.8							Fee Schedule																													106.79							Fee Schedule																																															
BLAKEMORE TUBE #0092220 (BARD MEDICAL)	272	RC						Both			1687	759.15	759.15	1518.3	1096.55							Fee Schedule		1248.38							Fee Schedule																													1518.3							Fee Schedule																																															
BLASTOMYCES ABS 932 1ML SERUM	302	RC	86612	CPT				Both			85.05	38.27	11.47	76.55	11.47							Fee Schedule		14.34							Fee Schedule		13.29							Fee Schedule		12.9							Fee Schedule		12.9							Fee Schedule		76.55							Fee Schedule		14.84							Fee Schedule		12							Fee Schedule		12.9							Fee Schedule		14.84							Fee Schedule		12							Fee Schedule		
"BLASTOMYCES ANTIGEN QN, UR OR BLD 15109"	302	RC	87449	CPT				Both			288.75	129.94	10.66	259.88	10.66							Fee Schedule		13.32							Fee Schedule		12.34							Fee Schedule		11.98							Fee Schedule		11.98							Fee Schedule		259.88							Fee Schedule		13.78							Fee Schedule		11.14							Fee Schedule		11.98							Fee Schedule		13.78							Fee Schedule		11.14							Fee Schedule		
BLEPHAMIDE 10-0.2% OPTHL OINTMENT-3.5GM	250	RC	A9270	CPT				Both			550.2	247.59	0.01	495.18	0.01							Fee Schedule		407.15							Fee Schedule																													495.18							Fee Schedule																																															
BLEPHAMIDE 10-0.2% OPTHL SOLUTION-5ML	250	RC	A9270	CPT				Both			550.2	247.59	0.01	495.18	0.01							Fee Schedule		407.15							Fee Schedule																													495.18							Fee Schedule																																															
BLOOD BANK AUTHOR DEVIATION	305	RC	86079	CPT				Both			200.55	90.25	36.49	180.5	36.49							Fee Schedule									Other	No Additional Reimbursement 																												180.5							Fee Schedule																																															
BLOOD BANK PHY INVESTIGATION	305	RC	86078	CPT				Both			200.55	90.25	36.72	180.5	36.72							Fee Schedule									Other	No Additional Reimbursement 																												180.5							Fee Schedule																																															
BLOOD BANK PHY SERVICE DIFFICULT X-MATCH	305	RC	86077	CPT				Both			204.75	92.14	36.72	184.28	36.72							Fee Schedule		53.66							Fee Schedule											48.98							Fee Schedule											184.28							Fee Schedule																																															
BLOOD GAS	301	RC	82805	CPT				Both			73.5	33.08	33.08	90.59	56.71							Fee Schedule		78.77							Fee Schedule		81.13							Fee Schedule		78.77							Fee Schedule		78.77							Fee Schedule		66.15							Fee Schedule		90.59							Fee Schedule		73.26							Fee Schedule		78.77							Fee Schedule		90.59							Fee Schedule		73.26							Fee Schedule		
BLOOD GAS	301	RC	82803	CPT				Both			165.9	74.66	18.77	149.31	18.77							Fee Schedule		26.07							Fee Schedule		26.85							Fee Schedule		26.07							Fee Schedule		26.07							Fee Schedule		149.31							Fee Schedule		29.98							Fee Schedule		24.25							Fee Schedule											29.98							Fee Schedule		24.25							Fee Schedule		
BLOOD GAS ARTERIAL NEWBORN	301	RC						Both			165.9	74.66	74.66	149.31	107.84							Fee Schedule		122.77							Fee Schedule																													149.31							Fee Schedule																																															
BLOOD GAS CORD BLOOD (ARTERIAL)	301	RC	82803	CPT				Both			97.65	43.94	18.77	87.89	18.77							Fee Schedule		26.07							Fee Schedule		26.85							Fee Schedule		26.07							Fee Schedule		26.07							Fee Schedule		87.89							Fee Schedule		29.98							Fee Schedule		24.25							Fee Schedule											29.98							Fee Schedule		24.25							Fee Schedule		
BLOOD GAS CORD BLOOD (VENOUS)	301	RC	82803	CPT				Both			97.65	43.94	18.77	87.89	18.77							Fee Schedule		26.07							Fee Schedule		26.85							Fee Schedule		26.07							Fee Schedule		26.07							Fee Schedule		87.89							Fee Schedule		29.98							Fee Schedule		24.25							Fee Schedule											29.98							Fee Schedule		24.25							Fee Schedule		
BLOOD GAS HEEL STK	301	RC	82805	CPT				Both			165.9	74.66	56.71	149.31	56.71							Fee Schedule		78.77							Fee Schedule		81.13							Fee Schedule		78.77							Fee Schedule		78.77							Fee Schedule		149.31							Fee Schedule		90.59							Fee Schedule		73.26							Fee Schedule		78.77							Fee Schedule		90.59							Fee Schedule		73.26							Fee Schedule		
BLOOD GAS KITS 4645P-2	272	RC						Both			3	1.35	1.35	2.7	1.95							Fee Schedule		2.22							Fee Schedule																													2.7							Fee Schedule																																															
BLOOD GAS VENOUS	301	RC	82803	CPT				Both			165.9	74.66	18.77	149.31	18.77							Fee Schedule		26.07							Fee Schedule		26.85							Fee Schedule		26.07							Fee Schedule		26.07							Fee Schedule		149.31							Fee Schedule		29.98							Fee Schedule		24.25							Fee Schedule											29.98							Fee Schedule		24.25							Fee Schedule		
BLOOD GAS W/LACTATE	301	RC	83605	CPT				Both			171.15	77.02	9.5	154.04	9.5							Fee Schedule		11.87							Fee Schedule		11.92							Fee Schedule		11.57							Fee Schedule		11.57							Fee Schedule		154.04							Fee Schedule		13.31							Fee Schedule		10.76							Fee Schedule											13.31							Fee Schedule		10.76							Fee Schedule		
BLOOD PRESS CUFF 2T ISOL ADULT #MDS9733	270	RC						Both			22	9.9	9.9	19.8	14.3							Fee Schedule		16.28							Fee Schedule																													19.8							Fee Schedule																																															
BLOOD PRESS CUFF 2T ISOL CHILD #MDS9731	270	RC						Both			38	17.1	17.1	34.2	24.7							Fee Schedule		28.12							Fee Schedule																													34.2							Fee Schedule																																															
BLOOD PRESS CUFF 2T ISOL LG ADT #MDS9734	270	RC						Both			39.9	17.96	17.96	35.91	25.94							Fee Schedule		29.53							Fee Schedule																													35.91							Fee Schedule																																															
BLOOD PROCESSING PLASMA	392	RC	P9017	CPT				Both			315	141.75	24.04	283.5	64.95							Fee Schedule		233.1							Fee Schedule		88.56							Fee Schedule		24.04							Fee Schedule		85.98							Fee Schedule		283.5							Fee Schedule		98.88							Fee Schedule		79.96							Fee Schedule		160							Case Rate		98.88							Fee Schedule		79.96							Fee Schedule		
BLOOD PROCESSING RBC'S	392	RC	P9016	CPT				Both			756	340.2	74.58	680.4	240.18							Fee Schedule		559.44							Fee Schedule		190.46							Fee Schedule		74.58							Fee Schedule		184.91							Fee Schedule		680.4							Fee Schedule		212.65							Fee Schedule		171.97							Fee Schedule		160							Case Rate		212.65							Fee Schedule		171.97							Fee Schedule		
BLOOD SET CLEARLINK Y-TYPE 2C8720	272	RC						Both			11.55	5.2	5.2	10.4	7.51							Fee Schedule		8.55							Fee Schedule																													10.4							Fee Schedule																																															
BLOOD SET INTERLINK STRAIGHT-TYPE 2C6700	272	RC						Both			6.3	2.84	2.84	5.67	4.1							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
BLOOD SET INTERLINK Y-TYPE 2C6720	272	RC						Both			10.5	4.73	4.73	9.45	6.83							Fee Schedule		7.77							Fee Schedule																													9.45							Fee Schedule																																															
BLOOD SET PURCHASING #2C8750	272	RC						Both			21	9.45	9.45	18.9	13.65							Fee Schedule		15.54							Fee Schedule																													18.9							Fee Schedule																																															
BLOOD SET UP SUPPLIES	272	RC						Both			105	47.25	47.25	94.5	68.25							Fee Schedule		77.7							Fee Schedule																													94.5							Fee Schedule																																															
BLOOD SET Y-TYPE ANESTHESIA #4C8723	272	RC						Both			17.85	8.03	8.03	16.07	11.6							Fee Schedule		13.21							Fee Schedule																													16.07							Fee Schedule																																															
BLOOD SET Y-TYPE NO VALVE 2C7627	272	RC						Both			6.3	2.84	2.84	5.67	4.1							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
BLOOD SMEAR	305	RC	85060	CPT				Both			85.05	38.27	17.54	76.55	17.54							Fee Schedule		62.94							Fee Schedule											20.79							Fee Schedule											76.55							Fee Schedule																																															
BLOX BITE BLOCK 60F #SBT-546-100	271	RC						Both			7	3.15	3.15	6.3	4.55							Fee Schedule		5.18							Fee Schedule																													6.3							Fee Schedule																																															
BLUE ACAPELLA  FLUTTER VALVE #V27-8000	272	RC						Both			89	40.05	40.05	80.1	57.85							Fee Schedule		65.86							Fee Schedule																													80.1							Fee Schedule																																															
BLUE DIGIFLEX	270	RC						Both			39.9	17.96	17.96	35.91	25.94							Fee Schedule		29.53							Fee Schedule																													35.91							Fee Schedule																																															
BLUE PRE-TAPING UNDERWRAP #92095	271	RC						Both			4	1.8	1.8	3.6	2.6							Fee Schedule		2.96							Fee Schedule																													3.6							Fee Schedule																																															
BLUE VOGUE SLING LG 7984-157	274	RC						Both			25.2	11.34	11.34	22.68		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	18.65							Fee Schedule																													22.68							Fee Schedule																																															
BLUE VOGUE SLING MED 7984-155	274	RC						Both			25.2	11.34	11.34	22.68		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	18.65							Fee Schedule																													22.68							Fee Schedule																																															
BLUE VOGUE SLING SM 7984-153	274	RC						Both			25.2	11.34	11.34	22.68		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	18.65							Fee Schedule																													22.68							Fee Schedule																																															
BLUNT CANNULA (303345)	272	RC						Both			1.05	0.47	0.47	0.95	0.68							Fee Schedule		0.78							Fee Schedule																													0.95							Fee Schedule																																															
BLUNT FILL NEEDLE 18G #SYR110022Z	272	RC						Both			1	0.45	0.45	0.9	0.65							Fee Schedule		0.74							Fee Schedule																													0.9							Fee Schedule																																															
BLUNT TIP SPINAL NEEDLE	272	RC						Both			23.1	10.4	10.4	20.79	15.02							Fee Schedule		17.09							Fee Schedule																													20.79							Fee Schedule																																															
BNP  BRAIN NATRIURETIC PEPTIDE LAVENDER	301	RC	83880	CPT				Both			256.2	115.29	30.17	230.58	30.17							Fee Schedule		39.26							Fee Schedule		40.44							Fee Schedule		39.26							Fee Schedule		39.26							Fee Schedule		230.58							Fee Schedule		45.15							Fee Schedule		36.51							Fee Schedule		39.26							Fee Schedule		45.15							Fee Schedule		36.51							Fee Schedule		
BNP  B-TYPE NATRIURETIC PEPTIDE 37386	301	RC	83880	CPT				Both			387	174.15	30.17	348.3	30.17							Fee Schedule		39.26							Fee Schedule		40.44							Fee Schedule		39.26							Fee Schedule		39.26							Fee Schedule		348.3							Fee Schedule		45.15							Fee Schedule		36.51							Fee Schedule		39.26							Fee Schedule		45.15							Fee Schedule		36.51							Fee Schedule		
BODY ALIGNER	270	RC						Both			42	18.9	18.9	37.8	27.3							Fee Schedule		31.08							Fee Schedule																													37.8							Fee Schedule																																															
BODY BAG #NON70548WM	271	RC						Both			23	10.35	10.35	20.7	14.95							Fee Schedule		17.02							Fee Schedule																													20.7							Fee Schedule																																															
BODY FL CELL CNT BC*TS	309	RC	89050	CPT				Both			38.85	17.48	4.2	34.97	4.2							Fee Schedule		5.25							Fee Schedule		4.86							Fee Schedule		4.72							Fee Schedule		4.72							Fee Schedule		34.97							Fee Schedule		5.43							Fee Schedule		4.39							Fee Schedule		4.72							Fee Schedule		5.43							Fee Schedule		4.39							Fee Schedule		
BODY FL CELL CNT W DIFF	309	RC	89051	CPT				Both			38.85	17.48	4.9	34.97	4.9							Fee Schedule		6.12							Fee Schedule		5.77							Fee Schedule		5.6							Fee Schedule		5.6							Fee Schedule		34.97							Fee Schedule		6.44							Fee Schedule		5.21							Fee Schedule		5.6							Fee Schedule		6.44							Fee Schedule		5.21							Fee Schedule		
BODY ICE THERAPY WRAP CERVICAL	270	RC						Both			47.25	21.26	21.26	42.53	30.71							Fee Schedule		34.97							Fee Schedule																													42.53							Fee Schedule																																															
BODY ICE THERAPY WRAP LG UNIVERSAL	270	RC						Both			59.85	26.93	26.93	53.87	38.9							Fee Schedule		44.29							Fee Schedule																													53.87							Fee Schedule																																															
BODY LOTION 8OZ #MSC092308	270	RC	A6250	CPT				Both			10	4.5	0.03	9	0.03							Fee Schedule		7.4							Fee Schedule																													9							Fee Schedule																																															
BONE AGE STUDY	320	RC	77072	CPT				Both			315	141.75	9.6	318	10.94							Fee Schedule		13.18							Fee Schedule											9.6							Fee Schedule											283.5							Fee Schedule																				318							Per Diem																				
BONE CEMENT & BOWL	278	RC						Both			298.2	134.19	134.19	268.38		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	220.67							Fee Schedule																													268.38							Fee Schedule																																															
BONE CEMENT ENDURANCE	278	RC						Both			286.65	128.99	128.99	257.99		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	212.12							Fee Schedule																													257.99							Fee Schedule																																															
BONE CHIPS CANC. 15CC (4-10MM) 00600618	278	RC	C1762	CPT				Both			1032	464.4	464.4	928.8		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	763.68							Fee Schedule																													928.8							Fee Schedule																																															
BONE CHIPS CANC. 5 CC (1-4MM) 00500418	278	RC	C1762	CPT				Both			519.75	233.89	233.89	467.78		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	384.62							Fee Schedule																													467.78							Fee Schedule																																															
BONE CHIPS CANC. 5 CC (4-10MM) 00600418	278	RC	C1762	CPT				Both			519.75	233.89	233.89	467.78		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	384.62							Fee Schedule																													467.78							Fee Schedule																																															
BONE CHIPS CANCELLOUS   30CC 400150	278	RC	C1762	CPT				Both			1017	457.65	457.65	915.3		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	752.58							Fee Schedule																													915.3							Fee Schedule																																															
BONE CRUSHED CANCELLOUS 15CC 400075	278	RC	C1762	CPT				Both			777	349.65	349.65	699.3		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	574.98							Fee Schedule																													699.3							Fee Schedule																																															
MAJOR CHEST PROCEDURES WITH MCC					163	DRG		Inpatient			136394.28	61377.43	61377.43	61377.43							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period	
BONE GRAFT CORTICAL	278	RC	C1762	CPT				Both			1096.2	493.29	493.29	986.58		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	811.19							Fee Schedule																													986.58							Fee Schedule																																															
BONE MARROW ASPIRATION	305	RC	38220	CPT				Both			248.85	111.98	86.23	223.97	86.23							Fee Schedule		184.15							Fee Schedule																													223.97							Fee Schedule																																															
BONE MARROW BIOPSY	370	RC	38221	CPT				Both			4634.25	2085.41	89.01	4170.83	89.01							Fee Schedule		3429.35							Fee Schedule																													4170.83							Fee Schedule																																															
BONE MARROW BIOPSY & ASPIRATION	370	RC	38222	CPT				Both			4634.25	2085.41	98.8	4170.83	98.8							Fee Schedule		3429.35							Fee Schedule																													4170.83							Fee Schedule																																															
BONE MARROW SMEAR INTERP ONLY	305	RC	85097	CPT				Both			320.25	144.11	35.32	288.23	35.32							Fee Schedule		71.19							Fee Schedule											63.65							Fee Schedule											288.23							Fee Schedule																																															
BONE MARROW SMEAR INTERPRETATION	305	RC	85097	CPT				Both			320.25	144.11	35.32	288.23	35.32							Fee Schedule		71.19							Fee Schedule											63.65							Fee Schedule											288.23							Fee Schedule																																															
BONE MARROW TRAY JAMSHIDI #BEJS4511SP	272	RC	A4550	CPT				Both			216	97.2	15.31	194.4	15.31							Fee Schedule		159.84							Fee Schedule											36.53							Fee Schedule											194.4							Fee Schedule																																															
BONE PREP KIT (STRYKER) 206-710	272	RC						Both			333	149.85	149.85	299.7	216.45							Fee Schedule		246.42							Fee Schedule																													299.7							Fee Schedule																																															
BONE WAX W31G	272	RC						Both			16	7.2	7.2	14.4	10.4							Fee Schedule		11.84							Fee Schedule																													14.4							Fee Schedule																																															
BOOSTRIX (TDAP)ADOLESCENT AND ADULT	636	RC	90715	CPT				Both			61.95	27.88	27.88	55.76		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	45.84							Fee Schedule		41.5							Fee Schedule											40.29							Fee Schedule		55.76							Fee Schedule		46.33							Fee Schedule		37.47							Fee Schedule											46.33							Fee Schedule		37.47							Fee Schedule		
BOOSTRIX (TDAP)ADOLESCENT AND ADULT SYR	636	RC	90715	CPT				Both			61.95	27.88	27.88	55.76		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	45.84							Fee Schedule		41.5							Fee Schedule											40.29							Fee Schedule		55.76							Fee Schedule		46.33							Fee Schedule		37.47							Fee Schedule											46.33							Fee Schedule		37.47							Fee Schedule		
BORD  PERT CULT 5260 NASAL SWAB	306	RC	87081	CPT				Both			74.55	33.55	5.89	67.1	5.89							Fee Schedule		7.36							Fee Schedule		6.83							Fee Schedule		6.63							Fee Schedule		6.63							Fee Schedule		67.1							Fee Schedule		7.62							Fee Schedule		6.17							Fee Schedule		6.63							Fee Schedule		7.62							Fee Schedule		6.17							Fee Schedule		
BORDERED GAUZE 4X4  #MSC3244Z	272	RC	A6219	CPT				Both			1	0.45	0.45	1.56	0.86							Fee Schedule		0.74							Fee Schedule		1.4							Fee Schedule		1.08							Fee Schedule		1.36							Fee Schedule		0.9							Fee Schedule		1.56							Fee Schedule		1.26							Fee Schedule											1.56							Fee Schedule		1.26							Fee Schedule		
BORDERED GAUZE 6X6  #MSC3266Z	272	RC	A6219	CPT				Both			2	0.9	0.86	1.8	0.86							Fee Schedule		1.48							Fee Schedule		1.4							Fee Schedule		1.08							Fee Schedule		1.36							Fee Schedule		1.8							Fee Schedule		1.56							Fee Schedule		1.26							Fee Schedule											1.56							Fee Schedule		1.26							Fee Schedule		
BORDETELLA PERTUS D F A 34966  2 SLIDES	306	RC	87265	CPT				Both			191.1	86	10.66	171.99	10.66							Fee Schedule		13.32							Fee Schedule		12.34							Fee Schedule		11.98							Fee Schedule		11.98							Fee Schedule		171.99							Fee Schedule		13.78							Fee Schedule		11.14							Fee Schedule		11.98							Fee Schedule		13.78							Fee Schedule		11.14							Fee Schedule		
BORDETELLA PERTUS IGG AB 17826 1ML SER	302	RC	86615	CPT				Both			206.85	93.08	11.72	186.17	11.72							Fee Schedule		14.65							Fee Schedule		13.59							Fee Schedule		13.19							Fee Schedule		13.19							Fee Schedule		186.17							Fee Schedule		15.17							Fee Schedule		12.27							Fee Schedule		13.19							Fee Schedule		15.17							Fee Schedule		12.27							Fee Schedule		
BORDETELLA PERTUSSIS DNA 11365 NASO SWAB	300	RC	87798	CPT				Both			210	94.5	31.2	189	31.2							Fee Schedule		38.99							Fee Schedule		36.14							Fee Schedule		35.09							Fee Schedule		35.09							Fee Schedule		189							Fee Schedule		40.35							Fee Schedule		32.63							Fee Schedule		35.09							Fee Schedule		40.35							Fee Schedule		32.63							Fee Schedule		
BORIC ACID OINT 10%	250	RC	A9270	CPT				Both			2.55	1.15	0.01	2.3	0.01							Fee Schedule		1.89							Fee Schedule																													2.3							Fee Schedule																																															
"BORRELIA SPECIES DNA, QUAL PCR 15777"	300	RC	87801	CPT				Both			639	287.55	62.4	575.1	62.4							Fee Schedule		77.99							Fee Schedule		72.31							Fee Schedule		70.2							Fee Schedule		70.2							Fee Schedule		575.1							Fee Schedule		80.73							Fee Schedule		65.29							Fee Schedule		70.2							Fee Schedule		80.73							Fee Schedule		65.29							Fee Schedule		
BOTOX 100 UNITS INJECTION	636	RC	J0585	CPT				Both			2325.6	1046.52	5.66	2093.04		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	6.51							Fee Schedule		6.71							Fee Schedule		5.66							Fee Schedule		6.51							Fee Schedule		2093.04							Fee Schedule		7.49							Fee Schedule		6.05							Fee Schedule											7.49							Fee Schedule		6.05							Fee Schedule		
BOUGIE TIP 15FR. #792-9-0212-70EA	272	RC						Both			17	7.65	7.65	15.3	11.05							Fee Schedule		12.58							Fee Schedule																													15.3							Fee Schedule																																															
BOVIE ELECTRODE ANGLED BLADE ES18	272	RC						Both			15.75	7.09	7.09	14.18	10.24							Fee Schedule		11.66							Fee Schedule																													14.18							Fee Schedule																																															
BOVIE ELECTRODE BLUNT DERMAL TIP A807	272	RC						Both			3.15	1.42	1.42	2.84	2.05							Fee Schedule		2.33							Fee Schedule																													2.84							Fee Schedule																																															
BOVIE LEG PADS ADULT DUAL #410-2000	272	RC						Both			11	4.95	4.95	9.9	7.15							Fee Schedule		8.14							Fee Schedule																													9.9							Fee Schedule																																															
BOVIE NEEDLE ELECTRODE ES02R	272	RC						Both			3	1.35	1.35	2.7	1.95							Fee Schedule		2.22							Fee Schedule																													2.7							Fee Schedule																																															
BOVIE NEEDLE INSULATED 138105 ( MEDLINE	272	RC						Both			4.95	2.23	2.23	4.46	3.22							Fee Schedule		3.66							Fee Schedule																													4.46							Fee Schedule																																															
BOVIE PADS PED. DUAL # 51-7710 (CONMED)	272	RC						Both			12	5.4	5.4	10.8	7.8							Fee Schedule		8.88							Fee Schedule																													10.8							Fee Schedule																																															
BOVIE PENCIL #60-0300-551 NEW#131309A	272	RC						Both			30	13.5	13.5	27	19.5							Fee Schedule		22.2							Fee Schedule																													27							Fee Schedule																																															
BOVIE PENCIL PUSH BUTTON #60-7510-005	272	RC						Both			78.75	35.44	35.44	70.88	51.19							Fee Schedule		58.28							Fee Schedule																													70.88							Fee Schedule																																															
BOVIE REDUCER SMOKE EVAC TUBING #SERFS	272	RC						Both			27	12.15	12.15	24.3	17.55							Fee Schedule		19.98							Fee Schedule																													24.3							Fee Schedule																																															
BOVIE SCRATCH PADS 138029 *DISC*	272	RC						Both			3.15	1.42	1.42	2.84	2.05							Fee Schedule		2.33							Fee Schedule																													2.84							Fee Schedule																																															
BOVIE TIP #88-000013C DEROYAL	272	RC						Both			16	7.2	7.2	14.4	10.4							Fee Schedule		11.84							Fee Schedule																													14.4							Fee Schedule																																															
BOVIE TIP #E1450-6 VALLEYLAB	272	RC						Both			21	9.45	9.45	18.9	13.65							Fee Schedule		15.54							Fee Schedule																													18.9							Fee Schedule																																															
BOVIE TIP (AA11)  ESCT003 MEDLINE	272	RC						Both			32	14.4	14.4	28.8	20.8							Fee Schedule		23.68							Fee Schedule																													28.8							Fee Schedule																																															
BOVIE TIP ARTHROCSCOPY	272	RC						Both			78.75	35.44	35.44	70.88	51.19							Fee Schedule		58.28							Fee Schedule																													70.88							Fee Schedule																																															
BOVIE TIPS EXTENDED TIP #E1551-6	272	RC						Both			17	7.65	7.65	15.3	11.05							Fee Schedule		12.58							Fee Schedule																													15.3							Fee Schedule																																															
BRACE TLSO	274	RC	L0486	CPT				Both			6960.45	3132.2	2014.94	6264.41		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	5150.73							Fee Schedule		2231.6							Fee Schedule											2166.6							Fee Schedule		6264.41							Fee Schedule		2491.59							Fee Schedule		2014.94							Fee Schedule											2491.59							Fee Schedule		2014.94							Fee Schedule		
BRACE TLSO CUSTOM	274	RC	L0468	CPT				Both			2016	907.2	550.71	1814.4		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1491.84							Fee Schedule		609.92							Fee Schedule											592.16							Fee Schedule		1814.4							Fee Schedule		680.98							Fee Schedule		550.71							Fee Schedule											680.98							Fee Schedule		550.71							Fee Schedule		
BRAF GENE ANAYLSIS	310	RC	81210	CPT				Both			630	283.5	126.29	567	126.29							Fee Schedule		175.4							Fee Schedule		180.66							Fee Schedule		175.4							Fee Schedule		175.4							Fee Schedule		567							Fee Schedule		201.71							Fee Schedule		163.12							Fee Schedule											201.71							Fee Schedule		163.12							Fee Schedule		
BRAF GENE ANAYLSIS	310	RC	81210	CPT				Both			630	283.5	126.29	567	126.29							Fee Schedule		175.4							Fee Schedule		180.66							Fee Schedule		175.4							Fee Schedule		175.4							Fee Schedule		567							Fee Schedule		201.71							Fee Schedule		163.12							Fee Schedule											201.71							Fee Schedule		163.12							Fee Schedule		
BRAUN 1WAY STOPCOCK 622501	272	RC						Both			18.9	8.51	8.51	17.01	12.29							Fee Schedule		13.99							Fee Schedule																													17.01							Fee Schedule																																															
BRAUN 3WAY STOPCOCK 622500	272	RC						Both			17	7.65	7.65	15.3	11.05							Fee Schedule		12.58							Fee Schedule																													15.3							Fee Schedule																																															
BRAUN EPIDURAL NEEDLE 18G 6' 332160	272	RC						Both			20	9	9	18	13							Fee Schedule		14.8							Fee Schedule																													18							Fee Schedule																																															
BRAUN NERVE BLOCK SUPPORT TRAY NB100	272	RC	A4550	CPT				Both			40	18	15.31	36.53	15.31							Fee Schedule		29.6							Fee Schedule											36.53							Fee Schedule											36							Fee Schedule																																															
BRAUN STIMUPLEX INSULATED NEEDLE 4894260	272	RC	A4215	CPT				Both			37	16.65	0.13	33.3	0.15							Fee Schedule		27.38							Fee Schedule											0.13							Fee Schedule											33.3							Fee Schedule																																															
BRDCRE BIOP NDLE 14X10	272	RC						Both			132.3	59.54	59.54	119.07	86							Fee Schedule		97.9							Fee Schedule																													119.07							Fee Schedule																																															
BREAST BINDER LARGE FLORAL PRINT	270	RC						Both			81	36.45	36.45	72.9	52.65							Fee Schedule		59.94							Fee Schedule																													72.9							Fee Schedule																																															
BREAST BINDER MEDIUM FLORAL PRINT	270	RC						Both			81	36.45	36.45	72.9	52.65							Fee Schedule		59.94							Fee Schedule																													72.9							Fee Schedule																																															
BREAST BINDER SMALL FLORAL PRINT	270	RC						Both			76	34.2	34.2	68.4	49.4							Fee Schedule		56.24							Fee Schedule																													68.4							Fee Schedule																																															
BREAST BINDER XLG FLORAL PRINT	270	RC						Both			71	31.95	31.95	63.9	46.15							Fee Schedule		52.54							Fee Schedule																													63.9							Fee Schedule																																															
BREAST KIT 17152	271	RC						Both			73.5	33.08	33.08	66.15	47.78							Fee Schedule		54.39							Fee Schedule																													66.15							Fee Schedule																																															
BREAST NURSING PAD #2630	271	RC						Both			3	1.35	1.35	2.7	1.95							Fee Schedule		2.22							Fee Schedule																													2.7							Fee Schedule																																															
BREAST PUMP DUAL KIT (SENECA) 17152	272	RC						Both			87	39.15	39.15	78.3	56.55							Fee Schedule		64.38							Fee Schedule																													78.3							Fee Schedule																																															
BREAST PUMP HOLLISTER	271	RC						Both			81.9	36.86	36.86	73.71	53.24							Fee Schedule		60.61							Fee Schedule																													73.71							Fee Schedule																																															
BREAST SHIELD 17216M (SENECA)	271	RC						Both			20	9	9	18	13							Fee Schedule		14.8							Fee Schedule																													18							Fee Schedule																																															
BREATHE RIGHT SMALL/MEDIUM (10)	250	RC	A9270	CPT				Both			13.8	6.21	0.01	12.42	0.01							Fee Schedule		10.21							Fee Schedule																													12.42							Fee Schedule																																															
BREATHRITE MDI SPACER (TRI-ANIM)	271	RC						Both			18.9	8.51	8.51	17.01	12.29							Fee Schedule		13.99							Fee Schedule																													17.01							Fee Schedule																																															
BREO ELLIPTA 100/25 INHALATION	250	RC	A9270	CPT				Both			542.85	244.28	0.01	488.57	0.01							Fee Schedule		401.71							Fee Schedule																													488.57							Fee Schedule																																															
BREVIBLOC 2.5 GM/10 ML (250 MG/ML) AMP	250	RC						Both			262.5	118.13	118.13	236.25	170.63							Fee Schedule		194.25							Fee Schedule																													236.25							Fee Schedule																																															
BREVITAL SODIUM 500 MG/50 ML VIAL	250	RC						Both			142.8	64.26	64.26	128.52	92.82							Fee Schedule		105.67							Fee Schedule																													128.52							Fee Schedule																																															
BRIDION 200MG/2ML (SUGAMMADEX) VIAL	250	RC	A9270	CPT				Both			376.95	169.63	0.01	339.26	0.01							Fee Schedule		278.94							Fee Schedule																													339.26							Fee Schedule																																															
BRILINTA 60MG TABLET	250	RC	A9270	CPT				Both			24.15	10.87	0.01	21.74	0.01							Fee Schedule		17.87							Fee Schedule																													21.74							Fee Schedule																																															
BRILINTA 90MG TABLET	250	RC	A9270	CPT				Both			23.1	10.4	0.01	20.79	0.01							Fee Schedule		17.09							Fee Schedule																													20.79							Fee Schedule																																															
BRIMONIDINE 0.15% (ALPHAGAN-P) OPTH SOL	250	RC	A9270	CPT				Both			552.3	248.54	0.01	497.07	0.01							Fee Schedule		408.7							Fee Schedule																													497.07							Fee Schedule																																															
BROMALINE ORAL SOLUTION- 5 ML UD	250	RC	A9270	CPT				Both			4.2	1.89	0.01	3.78	0.01							Fee Schedule		3.11							Fee Schedule																													3.78							Fee Schedule																																															
BROMOCRIPTINE 2.5 MG TABLET	250	RC	A9270	CPT				Both			8.4	3.78	0.01	7.56	0.01							Fee Schedule		6.22							Fee Schedule																													7.56							Fee Schedule																																															
MAJOR CHEST PROCEDURES WITH CC					164	DRG		Inpatient			63398.13	28529.16	28529.16	28529.16							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period	
OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITH MCC					166	DRG		Inpatient			54098.79	24344.46	24344.46	24344.46							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback				28411.47	28411.47	28411.47	1 through 10									0		No services provided during 15 month lookback period	
BRONCHOCATH 35FR W/CPAP 125135	272	RC						Both			275	123.75	123.75	247.5	178.75							Fee Schedule		203.5							Fee Schedule																													247.5							Fee Schedule																																															
BRONCHOCATH 39FR 125139	272	RC						Both			275	123.75	123.75	247.5	178.75							Fee Schedule		203.5							Fee Schedule																													247.5							Fee Schedule																																															
BRONCHOCATH 41FR W/CPAP 125141	272	RC						Both			275	123.75	123.75	247.5	178.75							Fee Schedule		203.5							Fee Schedule																													247.5							Fee Schedule																																															
BRONCHOCATH W/CPAP 37FR. 125137	272	RC						Both			275	123.75	123.75	247.5	178.75							Fee Schedule		203.5							Fee Schedule																													247.5							Fee Schedule																																															
BRONCHOCATH W/CPAP 39FR. 125039	272	RC						Both			245	110.25	110.25	220.5	159.25							Fee Schedule		181.3							Fee Schedule																													220.5							Fee Schedule																																															
BROSELOW INTUBATION BLUE  7700BIN	272	RC						Both			153	68.85	68.85	137.7	99.45							Fee Schedule		113.22							Fee Schedule																													137.7							Fee Schedule																																															
BROSELOW INTUBATION GREEN 7700GIN	272	RC						Both			153	68.85	68.85	137.7	99.45							Fee Schedule		113.22							Fee Schedule																													137.7							Fee Schedule																																															
BROSELOW INTUBATION ORANGE 7700OIN	272	RC						Both			153	68.85	68.85	137.7	99.45							Fee Schedule		113.22							Fee Schedule																													137.7							Fee Schedule																																															
BROSELOW INTUBATION PURPLE 7700PIN	272	RC						Both			153	68.85	68.85	137.7	99.45							Fee Schedule		113.22							Fee Schedule																													137.7							Fee Schedule																																															
BROSELOW INTUBATION RED 7700RIN	272	RC						Both			153	68.85	68.85	137.7	99.45							Fee Schedule		113.22							Fee Schedule																													137.7							Fee Schedule																																															
BROSELOW INTUBATION WHITE 7700WIN	272	RC						Both			153	68.85	68.85	137.7	99.45							Fee Schedule		113.22							Fee Schedule																													137.7							Fee Schedule																																															
BROSELOW INTUBATION YELLOW 7700YIN	272	RC						Both			153	68.85	68.85	137.7	99.45							Fee Schedule		113.22							Fee Schedule																													137.7							Fee Schedule																																															
BROSELOW IO KIT BLUE #7700BIO ARMSTRONG	272	RC						Both			192	86.4	86.4	172.8	124.8							Fee Schedule		142.08							Fee Schedule																													172.8							Fee Schedule																																															
BROSELOW IO KIT GREEN #7700GIO ARMSTRONG	272	RC						Both			192	86.4	86.4	172.8	124.8							Fee Schedule		142.08							Fee Schedule																													172.8							Fee Schedule																																															
BROSELOW IO KIT ORANGE #7700OIO ARMSTRON	272	RC						Both			192	86.4	86.4	172.8	124.8							Fee Schedule		142.08							Fee Schedule																													172.8							Fee Schedule																																															
BROSELOW IO KIT PURPLE #7700PIO ARMSTRON	272	RC						Both			192	86.4	86.4	172.8	124.8							Fee Schedule		142.08							Fee Schedule																													172.8							Fee Schedule																																															
BROSELOW IO KIT RED #7700RIO ARMSTRONG	272	RC						Both			192	86.4	86.4	172.8	124.8							Fee Schedule		142.08							Fee Schedule																													172.8							Fee Schedule																																															
BROSELOW IO KIT WHITE 7700WIO ARMSTRONG	272	RC						Both			192	86.4	86.4	172.8	124.8							Fee Schedule		142.08							Fee Schedule																													172.8							Fee Schedule																																															
BROSELOW IO KIT YELLOW 7700YIO ARMSTRONG	272	RC						Both			192	86.4	86.4	172.8	124.8							Fee Schedule		142.08							Fee Schedule																													172.8							Fee Schedule																																															
BROSELOW IV KIT BLUE 7700BIV ARMSTRONG	272	RC						Both			152	68.4	68.4	136.8	98.8							Fee Schedule		112.48							Fee Schedule																													136.8							Fee Schedule																																															
BROSELOW IV KIT GREEN 7700GIV ARMSTRONG	272	RC						Both			152	68.4	68.4	136.8	98.8							Fee Schedule		112.48							Fee Schedule																													136.8							Fee Schedule																																															
BROSELOW IV KIT ORANGE 7700OIV ARMSTRONG	272	RC						Both			152	68.4	68.4	136.8	98.8							Fee Schedule		112.48							Fee Schedule																													136.8							Fee Schedule																																															
BROSELOW IV KIT PURPLE 7700PIV ARMSTRONG	272	RC						Both			152	68.4	68.4	136.8	98.8							Fee Schedule		112.48							Fee Schedule																													136.8							Fee Schedule																																															
BROSELOW IV KIT RED 7700RIV ARMSTRONG	272	RC						Both			152	68.4	68.4	136.8	98.8							Fee Schedule		112.48							Fee Schedule																													136.8							Fee Schedule																																															
BROSELOW IV KIT WHITE 7700WIV ARMSTRONG	272	RC						Both			152	68.4	68.4	136.8	98.8							Fee Schedule		112.48							Fee Schedule																													136.8							Fee Schedule																																															
BROSELOW IV KIT YELLOW 7700YIV ARMSTRONG	272	RC						Both			152	68.4	68.4	136.8	98.8							Fee Schedule		112.48							Fee Schedule																													136.8							Fee Schedule																																															
BROSELOW KIT BLUE #7700BIN ARMSTRONG	272	RC						Both			88.2	39.69	39.69	79.38	57.33							Fee Schedule		65.27							Fee Schedule																													79.38							Fee Schedule																																															
BROSELOW O2 KIT BLUE  7700BAW	272	RC						Both			56	25.2	25.2	50.4	36.4							Fee Schedule		41.44							Fee Schedule																													50.4							Fee Schedule																																															
BROSELOW O2 KIT GREEN  7700GAW	272	RC						Both			56	25.2	25.2	50.4	36.4							Fee Schedule		41.44							Fee Schedule																													50.4							Fee Schedule																																															
BROSELOW O2 KIT ORANGE 7700OAW	272	RC						Both			56	25.2	25.2	50.4	36.4							Fee Schedule		41.44							Fee Schedule																													50.4							Fee Schedule																																															
BROSELOW O2 KIT PURPLE  7700PAW	272	RC						Both			56	25.2	25.2	50.4	36.4							Fee Schedule		41.44							Fee Schedule																													50.4							Fee Schedule																																															
BROSELOW O2 KIT RED  7700RAW	272	RC						Both			56	25.2	25.2	50.4	36.4							Fee Schedule		41.44							Fee Schedule																													50.4							Fee Schedule																																															
BROSELOW O2 KIT WHITE  7700WAW	272	RC						Both			56	25.2	25.2	50.4	36.4							Fee Schedule		41.44							Fee Schedule																													50.4							Fee Schedule																																															
BROSELOW O2 KIT YELLOW  7700YAW	272	RC						Both			56	25.2	25.2	50.4	36.4							Fee Schedule		41.44							Fee Schedule																													50.4							Fee Schedule																																															
BROVIAC 6.6FR CATHETER 0600540 PERIPH	278	RC	A4300	CPT				Both			824	370.8	4.57	741.6		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	609.76							Fee Schedule											4.57							Fee Schedule											741.6							Fee Schedule																																															
BRUCELLA  AB 982   1ML SERUM	302	RC	86622	CPT				Both			147	66.15	7.94	132.3	7.94							Fee Schedule		9.92							Fee Schedule		9.2							Fee Schedule		8.93							Fee Schedule		8.93							Fee Schedule		132.3							Fee Schedule		10.27							Fee Schedule		8.3							Fee Schedule		8.93							Fee Schedule		10.27							Fee Schedule		8.3							Fee Schedule		
BRUSH CHANNEL #BR18105	270	RC						Both			30	13.5	13.5	27	19.5							Fee Schedule		22.2							Fee Schedule																													27							Fee Schedule																																															
BRUSH CHANNEL BR12236	270	RC						Both			30	13.5	13.5	27	19.5							Fee Schedule		22.2							Fee Schedule																													27							Fee Schedule																																															
BSS SOLUTION	636	RC	A4217	CPT				Both			45.54	20.49	3.53	40.99		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	33.7							Fee Schedule		3.91							Fee Schedule											3.8							Fee Schedule		40.99							Fee Schedule		4.37							Fee Schedule		3.53							Fee Schedule											4.37							Fee Schedule		3.53							Fee Schedule		
BTRFLY EXT 23X3/4 12	272	RC						Both			3.15	1.42	1.42	2.84	2.05							Fee Schedule		2.33							Fee Schedule																													2.84							Fee Schedule																																															
BUBBLE HUMIDIFIER #7900  (MEDLINE)	272	RC						Both			7	3.15	3.15	6.3	4.55							Fee Schedule		5.18							Fee Schedule																													6.3							Fee Schedule																																															
BUCKS TRACTION SPLINT LARGE DEROYAL	290	RC	E0870	CPT				Both			44	19.8	19.8	162.04	77.89							Fee Schedule		32.56							Fee Schedule		145.13							Fee Schedule											140.9							Fee Schedule		39.6							Fee Schedule		162.04							Fee Schedule		131.04							Fee Schedule											162.04							Fee Schedule		131.04							Fee Schedule		
BUCKS TRACTION SPLINT MED DEROYAL	290	RC	E0870	CPT				Both			44	19.8	19.8	162.04	77.89							Fee Schedule		32.56							Fee Schedule		145.13							Fee Schedule											140.9							Fee Schedule		39.6							Fee Schedule		162.04							Fee Schedule		131.04							Fee Schedule											162.04							Fee Schedule		131.04							Fee Schedule		
BUCKS TRACTION SPLINT SM  DEROYAL	290	RC	E0870	CPT				Both			44	19.8	19.8	162.04	77.89							Fee Schedule		32.56							Fee Schedule		145.13							Fee Schedule											140.9							Fee Schedule		39.6							Fee Schedule		162.04							Fee Schedule		131.04							Fee Schedule											162.04							Fee Schedule		131.04							Fee Schedule		
BUCKS TRACTION UNIVERSAL 79-99850	290	RC	E0870	CPT				Both			55	24.75	24.75	162.04	77.89							Fee Schedule		40.7							Fee Schedule		145.13							Fee Schedule											140.9							Fee Schedule		49.5							Fee Schedule		162.04							Fee Schedule		131.04							Fee Schedule											162.04							Fee Schedule		131.04							Fee Schedule		
BULB SYRINGE (OR) 4090 (MEDLINE)	272	RC						Both			2	0.9	0.9	1.8	1.3							Fee Schedule		1.48							Fee Schedule																													1.8							Fee Schedule																																															
BULB SYRINGE OLD#4172 HCS0910-2	272	RC						Both			2	0.9	0.9	1.8	1.3							Fee Schedule		1.48							Fee Schedule																													1.8							Fee Schedule																																															
BULKAMID BULKING AGENT 50050 (BOSTON)	278	RC	L8606	CPT				Both			3150	1417.5	262.11	2835		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	2331							Fee Schedule		290.3							Fee Schedule											281.84							Fee Schedule		2835							Fee Schedule		324.12							Fee Schedule		262.11							Fee Schedule											324.12							Fee Schedule		262.11							Fee Schedule		
BULL DOG CLIP 8MM	272	RC						Both			22.05	9.92	9.92	19.85	14.33							Fee Schedule		16.32							Fee Schedule																													19.85							Fee Schedule																																															
BULLOUS PEMPHIGOID AG BP 180 AB 16034	301	RC	83520	CPT				Both			97.65	43.94	12.43	87.89	12.43							Fee Schedule		17.27							Fee Schedule		17.79							Fee Schedule		17.27							Fee Schedule		17.27							Fee Schedule		87.89							Fee Schedule		19.86							Fee Schedule		16.06							Fee Schedule		17.27							Fee Schedule		19.86							Fee Schedule		16.06							Fee Schedule		
BULLOUS PEMPHIGOID BP 230 IGG 16136	301	RC	83520	CPT				Both			123.9	55.76	12.43	111.51	12.43							Fee Schedule		17.27							Fee Schedule		17.79							Fee Schedule		17.27							Fee Schedule		17.27							Fee Schedule		111.51							Fee Schedule		19.86							Fee Schedule		16.06							Fee Schedule		17.27							Fee Schedule		19.86							Fee Schedule		16.06							Fee Schedule		
BUMETANIDE 0.25 MG/ML- 2ML VIAL	250	RC						Both			6.3	2.84	2.84	5.67	4.1							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
BUMETANIDE 0.25 MG/ML-10 ML VIAL	250	RC	J1939	CPT				Both			12.6	5.67	0.46	11.34	8.19							Fee Schedule		9.32							Fee Schedule		0.51							Fee Schedule											0.5							Fee Schedule		11.34							Fee Schedule		0.57							Fee Schedule		0.46							Fee Schedule											0.57							Fee Schedule		0.46							Fee Schedule		
BUMETANIDE 0.25 MG/ML-2 ML VIAL	250	RC						Both			6.3	2.84	2.84	5.67	4.1							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
BUMETANIDE 0.5 MG TABLET UD	250	RC	A9270	CPT				Both			4.2	1.89	0.01	3.78	0.01							Fee Schedule		3.11							Fee Schedule																													3.78							Fee Schedule																																															
BUMETANIDE 1 MG (BUMEX) TABLET	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
BUMETANIDE 1 MG/4ML VIAL	250	RC	J1939	CPT				Both			12.6	5.67	0.46	11.34	8.19							Fee Schedule		9.32							Fee Schedule		0.51							Fee Schedule											0.5							Fee Schedule		11.34							Fee Schedule		0.57							Fee Schedule		0.46							Fee Schedule											0.57							Fee Schedule		0.46							Fee Schedule		
BUMEX STANDARD ER DRIP	250	RC	J1939	CPT				Both			17.68	7.96	0.46	15.91	11.49							Fee Schedule		13.08							Fee Schedule		0.51							Fee Schedule											0.5							Fee Schedule		15.91							Fee Schedule		0.57							Fee Schedule		0.46							Fee Schedule											0.57							Fee Schedule		0.46							Fee Schedule		
BUN	301	RC	84520	CPT				Both			52.5	23.63	3.51	47.25	3.51							Fee Schedule		4.39							Fee Schedule		4.07							Fee Schedule		3.95							Fee Schedule		3.95							Fee Schedule		47.25							Fee Schedule		4.54							Fee Schedule		3.67							Fee Schedule		3.95							Fee Schedule		4.54							Fee Schedule		3.67							Fee Schedule		
BUN UR 24HR 973	301	RC	84540	CPT				Both			36.75	16.54	4.22	33.08	4.22							Fee Schedule		5.56							Fee Schedule		5.73							Fee Schedule		5.56							Fee Schedule		5.56							Fee Schedule		33.08							Fee Schedule		6.39							Fee Schedule		5.17							Fee Schedule		5.56							Fee Schedule		6.39							Fee Schedule		5.17							Fee Schedule		
BUN UR RANDOM 1737 10 ML URINE REF	301	RC	84540	CPT				Both			36.75	16.54	4.22	33.08	4.22							Fee Schedule		5.56							Fee Schedule		5.73							Fee Schedule		5.56							Fee Schedule		5.56							Fee Schedule		33.08							Fee Schedule		6.39							Fee Schedule		5.17							Fee Schedule		5.56							Fee Schedule		6.39							Fee Schedule		5.17							Fee Schedule		
BUPIVACAINE 0.25%/EPI 10 ML SDV	250	RC	J0665	CPT				Both			15.18	6.83	0.01	13.66	9.87							Fee Schedule		11.23							Fee Schedule		0.01							Fee Schedule											0.01							Fee Schedule		13.66							Fee Schedule		0.01							Fee Schedule		0.01							Fee Schedule											0.01							Fee Schedule		0.01							Fee Schedule		
BUPIVACAINE 0.5% MPF-30 ML SDV	250	RC	J0665	CPT				Both			10.62	4.78	0.01	9.56	6.9							Fee Schedule		7.86							Fee Schedule		0.01							Fee Schedule											0.01							Fee Schedule		9.56							Fee Schedule		0.01							Fee Schedule		0.01							Fee Schedule											0.01							Fee Schedule		0.01							Fee Schedule		
BUPIVACAINE HCL INJECTION 0.5% MDV-50ML	636	RC	J0665	CPT				Both			6	2.7	0.01	5.4		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	4.44							Fee Schedule		0.01							Fee Schedule											0.01							Fee Schedule		5.4							Fee Schedule		0.01							Fee Schedule		0.01							Fee Schedule											0.01							Fee Schedule		0.01							Fee Schedule		
BUPIVACAINE/KETOROLAC/KETAMINE/50ML SYR	250	RC						Both			141.75	63.79	63.79	127.58	92.14							Fee Schedule		104.9							Fee Schedule																													127.58							Fee Schedule																																															
BUPIVACAINE/MELOXICAM 200MG/6MG-7MLVIAL	250	RC	J0668	CPT				Both			487.8	219.51	0.77	439.02	317.07							Fee Schedule		0.81							Fee Schedule		0.85							Fee Schedule											0.83							Fee Schedule		439.02							Fee Schedule		0.95							Fee Schedule		0.77							Fee Schedule											0.95							Fee Schedule		0.77							Fee Schedule		
BUPRENEX 0.3 MG/ML INJECTION	250	RC	J0592	CPT				Both			11.55	5.2	4.16	10.4	4.75							Fee Schedule		8.55							Fee Schedule		4.61							Fee Schedule											4.47							Fee Schedule		10.4							Fee Schedule		5.15							Fee Schedule		4.16							Fee Schedule											5.15							Fee Schedule		4.16							Fee Schedule		
BUPRENORPHINE 16314 URINE  10 ML	301	RC	80307	CPT				Both			91.35	41.11	41.11	82.22	51.72							Fee Schedule		64.65							Fee Schedule		64							Fee Schedule		62.14							Fee Schedule		62.14							Fee Schedule		82.22							Fee Schedule		71.46							Fee Schedule		57.79							Fee Schedule		62.14							Fee Schedule		71.46							Fee Schedule		57.79							Fee Schedule		
buPROPion  75 MG (WELLBUTRIN) TABLET	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
buPROPion 100 MG (WELLBUTRIN)  TABLETS	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
buPROPion SR 150 MG (WELLBUTRIN) TABLET	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
buPROPion XL 150 MG (WELLBUTRIN) TABLET	250	RC	A9270	CPT				Both			14.7	6.62	0.01	13.23	0.01							Fee Schedule		10.88							Fee Schedule																													13.23							Fee Schedule																																															
BURETROL SET #2C8862	272	RC						Both			26	11.7	11.7	23.4	16.9							Fee Schedule		19.24							Fee Schedule																													23.4							Fee Schedule																																															
BURN SHEETS STERILE SZY1700036EA  MEDLIN	272	RC	A6253	CPT				Both			10	4.5	4.5	10.38	5.7							Fee Schedule		7.4							Fee Schedule		9.3							Fee Schedule		7.13							Fee Schedule		9.03							Fee Schedule		9							Fee Schedule		10.38							Fee Schedule		8.4							Fee Schedule											10.38							Fee Schedule		8.4							Fee Schedule		
BURR 4.0MM STONECUTTER ELITE #72200728	272	RC						Both			275	123.75	123.75	247.5	178.75							Fee Schedule		203.5							Fee Schedule																													247.5							Fee Schedule																																															
BURR 5.5 STONECUTTER ELITE #72200729	272	RC						Both			111	49.95	49.95	99.9	72.15							Fee Schedule		82.14							Fee Schedule																													99.9							Fee Schedule																																															
BUSPIRONE  5 MG (BUSPAR) TABLET	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
BUSPIRONE 10 MG (BUSPAR) TABLET	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
BUSPIRONE 15 MG (BUSPAR)  TABLET	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
BUTALBITAL 4413 SERUM	300	RC	80307	CPT				Both			315	141.75	51.72	283.5	51.72							Fee Schedule		64.65							Fee Schedule		64							Fee Schedule		62.14							Fee Schedule		62.14							Fee Schedule		283.5							Fee Schedule		71.46							Fee Schedule		57.79							Fee Schedule		62.14							Fee Schedule		71.46							Fee Schedule		57.79							Fee Schedule		
BUTALBITAL/APAP/CAFF 50/300/40 MG	250	RC	A9270	CPT				Both			9.45	4.25	0.01	8.51	0.01							Fee Schedule		6.99							Fee Schedule																													8.51							Fee Schedule																																															
BUTORPHANOL 1 MG/ML INJECTION (STADOL)	636	RC	J0595	CPT				Both			14.7	6.62	6.62	13.23		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	10.88							Fee Schedule		10.82							Fee Schedule											10.51							Fee Schedule		13.23							Fee Schedule		12.08							Fee Schedule		9.77							Fee Schedule											12.08							Fee Schedule		9.77							Fee Schedule		
BUTORPHANOL 2 MG/ML INJECTION (STADOL)	636	RC	J0595	CPT				Both			18.9	8.51	8.51	17.01		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	13.99							Fee Schedule		10.82							Fee Schedule											10.51							Fee Schedule		17.01							Fee Schedule		12.08							Fee Schedule		9.77							Fee Schedule											12.08							Fee Schedule		9.77							Fee Schedule		
BUTTERFLY EXTENSION SET 19X7/8 (DISC.)	272	RC						Both			4.2	1.89	1.89	3.78	2.73							Fee Schedule		3.11							Fee Schedule																													3.78							Fee Schedule																																															
BUTTERFLY NEEDLE 21GX3/4 (FISHER)	272	RC						Both			1	0.45	0.45	0.9	0.65							Fee Schedule		0.74							Fee Schedule																													0.9							Fee Schedule																																															
BUTTERFLY NEEDLE 23GX3/4 (FISHER)	272	RC						Both			1.26	0.57	0.57	1.13	0.82							Fee Schedule		0.93							Fee Schedule																													1.13							Fee Schedule																																															
BUTTERFLY NEEDLE 25GX3/4 (FISHER)	272	RC						Both			1	0.45	0.45	0.9	0.65							Fee Schedule		0.74							Fee Schedule																													0.9							Fee Schedule																																															
BUTTRESS L PLATE	278	RC	C1713	CPT				Both			468.3	210.74	210.74	421.47		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	346.54							Fee Schedule																													421.47							Fee Schedule																																															
BYETTA  5 MCG/0.02ML-1.2ML INJECTION	636	RC	J3490	CPT				Both			653.1	293.9	293.9	587.79		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	483.29							Fee Schedule																													587.79							Fee Schedule																																															
BYETTA 10 MCG/0.04ML-2.4ML INJECTION	636	RC	J3490	CPT				Both			838.62	377.38	377.38	754.76		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	620.58							Fee Schedule																													754.76							Fee Schedule																																															
BYSTOLIC 5 MG (NEBIVOLOL) TAB	250	RC	A9270	CPT				Both			18.9	8.51	0.01	17.01	0.01							Fee Schedule		13.99							Fee Schedule																													17.01							Fee Schedule																																															
C ARM DRAPE VAE5601	270	RC						Both			18	8.1	8.1	16.2	11.7							Fee Schedule		13.32							Fee Schedule																													16.2							Fee Schedule																																															
C CAST 2 FOOT	271	RC	A4580	CPT				Both			17.85	8.03	8.03	23.72	9							Fee Schedule		13.21							Fee Schedule											23.72							Fee Schedule											16.07							Fee Schedule																																															
C CAST 3 FOOT	274	RC	A4580	CPT				Both			21	9.45	9.45	23.72		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	15.54							Fee Schedule											23.72							Fee Schedule											18.9							Fee Schedule																																															
C CAST 4 FOOT	274	RC	A4580	CPT				Both			26.25	11.81	11.81	23.72		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	19.43							Fee Schedule											23.72							Fee Schedule											23.63							Fee Schedule																																															
C DIFF TOXIN B PCR 16377 REF L. 5ML ST	300	RC	87493	CPT				Both			189	85.05	31.2	170.1	31.2							Fee Schedule		38.99							Fee Schedule		38.39							Fee Schedule		37.27							Fee Schedule		37.27							Fee Schedule		170.1							Fee Schedule		42.86							Fee Schedule		34.66							Fee Schedule		37.27							Fee Schedule		42.86							Fee Schedule		34.66							Fee Schedule		
C PEPTIDE 372 SERUM	301	RC	84681	CPT				Both			115.5	51.98	18.5	103.95	18.5							Fee Schedule		23.13							Fee Schedule		21.43							Fee Schedule		20.81							Fee Schedule		20.81							Fee Schedule		103.95							Fee Schedule		23.93							Fee Schedule		19.35							Fee Schedule		20.81							Fee Schedule		23.93							Fee Schedule		19.35							Fee Schedule		
C SECTION PACK NEW MEDLINE DYNJS0612	270	RC						Both			141.4	63.63	63.63	127.26	91.91							Fee Schedule		104.64							Fee Schedule																													127.26							Fee Schedule																																															
C TAPER HEAD	278	RC	C1776	CPT				Both			1517.25	682.76	682.76	1365.53		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1122.77							Fee Schedule																													1365.53							Fee Schedule																																															
C TAPER HEAD PRESS FIT	278	RC	C1776	CPT				Both			1598.1	719.15	719.15	1438.29		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1182.59							Fee Schedule																													1438.29							Fee Schedule																																															
C02 INSUFFLATION TUBING	272	RC						Both			21	9.45	9.45	18.9	13.65							Fee Schedule		15.54							Fee Schedule																													18.9							Fee Schedule																																															
C1 ESTERASE INHIBITOR 298  SERUM	302	RC	86160	CPT				Both			124.95	56.23	10.66	112.46	10.66							Fee Schedule		13.33							Fee Schedule		12.36							Fee Schedule		12							Fee Schedule		12							Fee Schedule		112.46							Fee Schedule		13.8							Fee Schedule		11.16							Fee Schedule		12							Fee Schedule		13.8							Fee Schedule		11.16							Fee Schedule		
C1 INHIBITOR FUNCTIONAL 297 SER FROZ	302	RC	83520	CPT				Both			99.75	44.89	12.43	89.78	12.43							Fee Schedule		17.27							Fee Schedule		17.79							Fee Schedule		17.27							Fee Schedule		17.27							Fee Schedule		89.78							Fee Schedule		19.86							Fee Schedule		16.06							Fee Schedule		17.27							Fee Schedule		19.86							Fee Schedule		16.06							Fee Schedule		
C1Q ANTIBODY (IGG)  34303	301	RC	83516	CPT				Both			270	121.5	10.25	243	10.25							Fee Schedule		12.81							Fee Schedule		11.88							Fee Schedule		11.53							Fee Schedule		11.53							Fee Schedule		243							Fee Schedule		13.26							Fee Schedule		10.72							Fee Schedule		11.53							Fee Schedule		13.26							Fee Schedule		10.72							Fee Schedule		
C2 COMPLEMENT 433 SERUM 1ML	302	RC	86160	CPT				Both			124.95	56.23	10.66	112.46	10.66							Fee Schedule		13.33							Fee Schedule		12.36							Fee Schedule		12							Fee Schedule		12							Fee Schedule		112.46							Fee Schedule		13.8							Fee Schedule		11.16							Fee Schedule		12							Fee Schedule		13.8							Fee Schedule		11.16							Fee Schedule		
C3 QUEST 351	302	RC	86160	CPT				Both			27.3	12.29	10.66	24.57	10.66							Fee Schedule		13.33							Fee Schedule		12.36							Fee Schedule		12							Fee Schedule		12							Fee Schedule		24.57							Fee Schedule		13.8							Fee Schedule		11.16							Fee Schedule		12							Fee Schedule		13.8							Fee Schedule		11.16							Fee Schedule		
C4 QUEST 353	302	RC	86160	CPT				Both			27.3	12.29	10.66	24.57	10.66							Fee Schedule		13.33							Fee Schedule		12.36							Fee Schedule		12							Fee Schedule		12							Fee Schedule		24.57							Fee Schedule		13.8							Fee Schedule		11.16							Fee Schedule		12							Fee Schedule		13.8							Fee Schedule		11.16							Fee Schedule		
CA 125  29256 CANCER ANTIGEN SERUM	302	RC	86304	CPT				Both			130.2	58.59	18.5	117.18	18.5							Fee Schedule		23.13							Fee Schedule		21.43							Fee Schedule		20.81							Fee Schedule		20.81							Fee Schedule		117.18							Fee Schedule		23.93							Fee Schedule		19.35							Fee Schedule		20.81							Fee Schedule		23.93							Fee Schedule		19.35							Fee Schedule		
CA 15 3  5819 CANCER ANTIGEN SERUM	302	RC	86300	CPT				Both			115.5	51.98	18.5	103.95	18.5							Fee Schedule		23.13							Fee Schedule		21.43							Fee Schedule		20.81							Fee Schedule		20.81							Fee Schedule		103.95							Fee Schedule		23.93							Fee Schedule		19.35							Fee Schedule		20.81							Fee Schedule		23.93							Fee Schedule		19.35							Fee Schedule		
CA 19 9  4698 CARBOHYD ANTIGEN	302	RC	86301	CPT				Both			115.5	51.98	18.5	103.95	18.5							Fee Schedule		23.13							Fee Schedule		21.43							Fee Schedule		20.81							Fee Schedule		20.81							Fee Schedule		103.95							Fee Schedule		23.93							Fee Schedule		19.35							Fee Schedule		20.81							Fee Schedule		23.93							Fee Schedule		19.35							Fee Schedule		
CA 27 29   29493 CANCER ANTIGEN SERUM	302	RC	86300	CPT				Both			115.5	51.98	18.5	103.95	18.5							Fee Schedule		23.13							Fee Schedule		21.43							Fee Schedule		20.81							Fee Schedule		20.81							Fee Schedule		103.95							Fee Schedule		23.93							Fee Schedule		19.35							Fee Schedule		20.81							Fee Schedule		23.93							Fee Schedule		19.35							Fee Schedule		
CABOT TRIPOLAR 6689-903	272	RC						Both			927.15	417.22	417.22	834.44	602.65							Fee Schedule		686.09							Fee Schedule																													834.44							Fee Schedule																																															
CADD EPIDURAL ADMINISTRA SET 21-7349-24	272	RC						Both			33	14.85	14.85	29.7	21.45							Fee Schedule		24.42							Fee Schedule																													29.7							Fee Schedule																																															
CADD IV SET REGULAR # 21-7322	272	RC						Both			72.45	32.6	32.6	65.21	47.09							Fee Schedule		53.61							Fee Schedule																													65.21							Fee Schedule																																															
CADD IV SET YELLOW # 21-7324	272	RC						Both			26.25	11.81	11.81	23.63	17.06							Fee Schedule		19.43							Fee Schedule																													23.63							Fee Schedule																																															
CADD IV SET YELLOW STRIPED 21-7105-24	272	RC						Both			8	3.6	3.6	7.2	5.2							Fee Schedule		5.92							Fee Schedule																													7.2							Fee Schedule																																															
CADD SOLIS PCA EXT. SET #21-7047 FLOORS	272	RC						Both			4.9	2.21	2.21	4.41	3.19							Fee Schedule		3.63							Fee Schedule																													4.41							Fee Schedule																																															
CADMIUM 299 W/B ROYAL BLUE TUBE	306	RC	82300	CPT				Both			126	56.7	20.58	113.4	20.58							Fee Schedule		25.72							Fee Schedule		24.35							Fee Schedule		23.64							Fee Schedule		23.64							Fee Schedule		113.4							Fee Schedule		27.19							Fee Schedule		21.99							Fee Schedule		23.64							Fee Schedule		27.19							Fee Schedule		21.99							Fee Schedule		
CADMIUM BLOOD	306	RC	82300	CPT				Both			126	56.7	20.58	113.4	20.58							Fee Schedule		25.72							Fee Schedule		24.35							Fee Schedule		23.64							Fee Schedule		23.64							Fee Schedule		113.4							Fee Schedule		27.19							Fee Schedule		21.99							Fee Schedule		23.64							Fee Schedule		27.19							Fee Schedule		21.99							Fee Schedule		
CAFFEINE 305 SERUM	301	RC	80299	CPT				Both			165.9	74.66	13.42	149.31	13.42							Fee Schedule		18.64							Fee Schedule		19.2							Fee Schedule		18.64							Fee Schedule		18.64							Fee Schedule		149.31							Fee Schedule		21.44							Fee Schedule		17.34							Fee Schedule		18.64							Fee Schedule		21.44							Fee Schedule		17.34							Fee Schedule		
CAFFEINE/SODIUM BENZOATE 250MG/ML-2ML VL	636	RC	J0706	CPT				Both			72.45	32.6	32.6	65.21		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	53.61							Fee Schedule																													65.21							Fee Schedule																																															
CALADRYL LOTION 180ML	250	RC	A9270	CPT				Both			14.7	6.62	0.01	13.23	0.01							Fee Schedule		10.88							Fee Schedule																													13.23							Fee Schedule																																															
CALAMINE LOTION -180ML	250	RC	A9270	CPT				Both			7.35	3.31	0.01	6.62	0.01							Fee Schedule		5.44							Fee Schedule																													6.62							Fee Schedule																																															
CALCIPOTRIENE 0.005% CREAM- 60GM MED	250	RC	A9270	CPT				Both			411.6	185.22	0.01	370.44	0.01							Fee Schedule		304.58							Fee Schedule																													370.44							Fee Schedule																																															
CALCITONIN 30742  SERUM	301	RC	82308	CPT				Both			149.1	67.1	23.82	134.19	23.82							Fee Schedule		29.77							Fee Schedule		27.59							Fee Schedule		26.79							Fee Schedule		26.79							Fee Schedule		134.19							Fee Schedule		30.81							Fee Schedule		24.91							Fee Schedule		26.79							Fee Schedule		30.81							Fee Schedule		24.91							Fee Schedule		
CALCITONIN-SALMON (MIACALCIN) NASAL SP	250	RC	A9270	CPT				Both			373.8	168.21	0.01	336.42	0.01							Fee Schedule		276.61							Fee Schedule																													336.42							Fee Schedule																																															
CALCITONIN-SALMON NASAL SPRAY 200 IU	250	RC	A9270	CPT				Both			373.8	168.21	0.01	336.42	0.01							Fee Schedule		276.61							Fee Schedule																													336.42							Fee Schedule																																															
CALCITRIOL 0.25 MCG CAPSULE	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
"CALCITRIOL 1,25 DIHYDROXY VIT D 16558"	301	RC	82652	CPT				Both			210	94.5	34.22	189	34.22							Fee Schedule		42.78							Fee Schedule		39.66							Fee Schedule		38.5							Fee Schedule		38.5							Fee Schedule		189							Fee Schedule		44.28							Fee Schedule		35.81							Fee Schedule		38.5							Fee Schedule		44.28							Fee Schedule		35.81							Fee Schedule		
CALCIUM	301	RC	82310	CPT				Both			36.75	16.54	4.59	33.08	4.59							Fee Schedule		5.73							Fee Schedule		5.31							Fee Schedule		5.16							Fee Schedule		5.16							Fee Schedule		33.08							Fee Schedule		5.93							Fee Schedule		4.8							Fee Schedule		5.16							Fee Schedule		5.93							Fee Schedule		4.8							Fee Schedule		
CALCIUM 500/200/ VIT D	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
CALCIUM 600+ VIT D 400 INT UNITS TAB	250	RC	A9270	CPT				Both			6	2.7	0.01	5.4	0.01							Fee Schedule		4.44							Fee Schedule																													5.4							Fee Schedule																																															
CALCIUM ACETATE 667MG TAB	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
CALCIUM ALG W/ SILVER ROPE 12  #60012-AG	272	RC	A6199	CPT				Both			8	3.6	3.6	8.65	4.76							Fee Schedule		5.92							Fee Schedule		7.75							Fee Schedule		5.95							Fee Schedule		7.52							Fee Schedule		7.2							Fee Schedule		8.65							Fee Schedule		6.99							Fee Schedule											8.65							Fee Schedule		6.99							Fee Schedule		
CALCIUM ALGINATE 2X2 #60022	272	RC	A6196	CPT				Both			3	1.35	1.35	12.06	6.62							Fee Schedule		2.22							Fee Schedule		10.8							Fee Schedule		8.28							Fee Schedule		10.49							Fee Schedule		2.7							Fee Schedule		12.06							Fee Schedule		9.76							Fee Schedule											12.06							Fee Schedule		9.76							Fee Schedule		
CALCIUM ALGINATE 4X4 #60044	272	RC	A6237	CPT				Both			4	1.8	1.8	12.96	7.13							Fee Schedule		2.96							Fee Schedule		11.61							Fee Schedule		8.91							Fee Schedule		11.27							Fee Schedule		3.6							Fee Schedule		12.96							Fee Schedule		10.48							Fee Schedule											12.96							Fee Schedule		10.48							Fee Schedule		
CALCIUM ALGINATE W/ SILVER 4X4 #60044-AG	272	RC	A6197	CPT				Both			10	4.5	4.5	26.96	14.8							Fee Schedule		7.4							Fee Schedule		24.14							Fee Schedule		18.5							Fee Schedule		23.44							Fee Schedule		9							Fee Schedule		26.96							Fee Schedule		21.8							Fee Schedule											26.96							Fee Schedule		21.8							Fee Schedule		
CALCIUM CARBONATE 500MG	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
CALCIUM CHLORIDE 10% (100MG/ML)-10ML MDV	250	RC						Both			6.3	2.84	2.84	5.67	4.1							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
CALCIUM CHLORIDE 10% PF SYR (1GM/10ML)	250	RC	A9270	CPT				Both			25.2	11.34	0.01	22.68	0.01							Fee Schedule		18.65							Fee Schedule																													22.68							Fee Schedule																																															
CALCIUM CHLORIDE 1GM/D5W 50ML IVPB	636	RC	J3475	CPT				Both			44.49	20.02	0.41	40.04		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	32.92							Fee Schedule		0.46							Fee Schedule		0.42							Fee Schedule		0.45							Fee Schedule		40.04							Fee Schedule		0.51							Fee Schedule		0.41							Fee Schedule											0.51							Fee Schedule		0.41							Fee Schedule		
CALCIUM CHLORIDE 2GM/D5W 250ML IVPB	636	RC	J3475	CPT				Both			44.49	20.02	0.41	40.04		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	32.92							Fee Schedule		0.46							Fee Schedule		0.42							Fee Schedule		0.45							Fee Schedule		40.04							Fee Schedule		0.51							Fee Schedule		0.41							Fee Schedule											0.51							Fee Schedule		0.41							Fee Schedule		
CALCIUM CHLORIDE 3GM/D5W 150ML IVPB	636	RC	J3475	CPT				Both			50.22	22.6	0.41	45.2		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	37.16							Fee Schedule		0.46							Fee Schedule		0.42							Fee Schedule		0.45							Fee Schedule		45.2							Fee Schedule		0.51							Fee Schedule		0.41							Fee Schedule											0.51							Fee Schedule		0.41							Fee Schedule		
CALCIUM GLUCONATE 10%-10ML SDV	636	RC	J0612	CPT				Both			34.65	15.59	0.03	31.19		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	25.64							Fee Schedule		0.03							Fee Schedule											0.03							Fee Schedule		31.19							Fee Schedule		0.03							Fee Schedule		0.03							Fee Schedule											0.03							Fee Schedule		0.03							Fee Schedule		
CALCIUM GLUCONATE 1GM/NS 50ML PREMIX	636	RC	J0612	CPT				Both			149.1	67.1	0.03	134.19		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	110.33							Fee Schedule		0.03							Fee Schedule											0.03							Fee Schedule		134.19							Fee Schedule		0.03							Fee Schedule		0.03							Fee Schedule											0.03							Fee Schedule		0.03							Fee Schedule		
CALCIUM GLUCONATE 2GM/100ML PREMIX	636	RC	J0613	CPT				Both			142.2	63.99	0.05	127.98		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	105.23							Fee Schedule		0.05							Fee Schedule											0.05							Fee Schedule		127.98							Fee Schedule		0.06							Fee Schedule		0.05							Fee Schedule											0.06							Fee Schedule		0.05							Fee Schedule		
CALCIUM IONIZED 306 SST TUBE SPUN UNOP	301	RC	82330	CPT				Both			85.05	38.27	12.15	76.55	12.15							Fee Schedule		15.2							Fee Schedule		14.09							Fee Schedule		13.68							Fee Schedule		13.68							Fee Schedule		76.55							Fee Schedule		15.73							Fee Schedule		12.72							Fee Schedule		13.68							Fee Schedule		15.73							Fee Schedule		12.72							Fee Schedule		
CALCIUM UR 24HR 1635	301	RC	82340	CPT				Both			36.75	16.54	5.36	33.08	5.36							Fee Schedule		6.7							Fee Schedule		6.21							Fee Schedule		6.03							Fee Schedule		6.03							Fee Schedule		33.08							Fee Schedule		6.93							Fee Schedule		5.61							Fee Schedule		6.03							Fee Schedule		6.93							Fee Schedule		5.61							Fee Schedule		
CALCIUM UR RAN 1633	301	RC	82340	CPT				Both			36.75	16.54	5.36	33.08	5.36							Fee Schedule		6.7							Fee Schedule		6.21							Fee Schedule		6.03							Fee Schedule		6.03							Fee Schedule		33.08							Fee Schedule		6.93							Fee Schedule		5.61							Fee Schedule		6.03							Fee Schedule		6.93							Fee Schedule		5.61							Fee Schedule		
CALL BACK LABOR/DEL	720	RC						Inpatient			787.5	354.38	11.26	796	500							Per Diem		582.75							Fee Schedule											11.26							Fee Schedule											708.75							Fee Schedule																				796							Case Rate																				
CALMOSEPTINE OINTMENT  120GM	250	RC	A9270	CPT				Both			15.75	7.09	0.01	14.18	0.01							Fee Schedule		11.66							Fee Schedule																													14.18							Fee Schedule																																															
CALRETICULIN MUTATION 92475 EDTA  WB RT	310	RC	81219	CPT				Both			577.5	259.88	108.12	519.75	108.12							Fee Schedule		135.14							Fee Schedule		125.28							Fee Schedule		121.63							Fee Schedule		121.63							Fee Schedule		519.75							Fee Schedule		139.87							Fee Schedule		113.12							Fee Schedule											139.87							Fee Schedule		113.12							Fee Schedule		
CAM WALKER LONG LG 79-95707	274	RC	L2116	CPT				Both			90	40.5	40.5	1010.57		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	66.6							Fee Schedule		905.12							Fee Schedule		622.43							Fee Schedule		878.76							Fee Schedule		81							Fee Schedule		1010.57							Fee Schedule		817.25							Fee Schedule											1010.57							Fee Schedule		817.25							Fee Schedule		
CAM WALKER LONG MED 79-95705	274	RC						Both			90	40.5	40.5	81		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	66.6							Fee Schedule																													81							Fee Schedule																																															
CAM WALKER LONG SMALL 79-95703	274	RC	L2116	CPT				Both			90	40.5	40.5	1010.57		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	66.6							Fee Schedule		905.12							Fee Schedule		622.43							Fee Schedule		878.76							Fee Schedule		81							Fee Schedule		1010.57							Fee Schedule		817.25							Fee Schedule											1010.57							Fee Schedule		817.25							Fee Schedule		
"CAMPYLOBACTER SP AG, EIA 16302 STOOL"	302	RC	87449	CPT				Both			27	12.15	10.66	24.3	10.66							Fee Schedule		13.32							Fee Schedule		12.34							Fee Schedule		11.98							Fee Schedule		11.98							Fee Schedule		24.3							Fee Schedule		13.78							Fee Schedule		11.14							Fee Schedule		11.98							Fee Schedule		13.78							Fee Schedule		11.14							Fee Schedule		
CANDESARTAN 16 MG TABLET UD	250	RC						Both			4.99	2.25	2.25	4.49	3.24							Fee Schedule		3.69							Fee Schedule																													4.49							Fee Schedule																																															
CANDIDA  ALBICANS AB 30440	302	RC	86628	CPT				Both			82.72	37.22	10.67	74.45	10.67							Fee Schedule		13.34							Fee Schedule		12.37							Fee Schedule		12.01							Fee Schedule		12.01							Fee Schedule		74.45							Fee Schedule		13.81							Fee Schedule		11.17							Fee Schedule		12.01							Fee Schedule		13.81							Fee Schedule		11.17							Fee Schedule		
CANDIDA SKIN TEST- 1ML MDV	250	RC						Both			78.75	35.44	35.44	70.88	51.19							Fee Schedule		58.28							Fee Schedule																													70.88							Fee Schedule																																															
CANE ALUMINUM ADJUSTABLE (MEDLINE)	270	RC						Both			14.25	6.41	6.41	12.83	9.26							Fee Schedule		10.55							Fee Schedule																													12.83							Fee Schedule																																															
"CANNABINOID PANEL, SERUM, PLASMA 19969"	301	RC	80349	CPT				Both			393	176.85	0.01	353.7	0.01							Fee Schedule									Other	No Additional Reimbursement 																												353.7							Fee Schedule																																															
CANNABINOIDS 8421 SERUM 5ML REFRIG	301	RC	82542	CPT				Both			130.2	58.59	17.34	117.18	17.34							Fee Schedule		24.09							Fee Schedule		24.81							Fee Schedule		24.09							Fee Schedule		24.09							Fee Schedule		117.18							Fee Schedule		27.7							Fee Schedule		22.4							Fee Schedule		24.09							Fee Schedule		27.7							Fee Schedule		22.4							Fee Schedule		
"CANNABINOIDS PNL, SERUM 19969"	301	RC	80349	CPT				Both			369	166.05	0.01	332.1	0.01							Fee Schedule									Other	No Additional Reimbursement 																												332.1							Fee Schedule																																															
CANNELL 6.5 BONE SCR	278	RC						Both			219.45	98.75	98.75	197.51		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	162.39							Fee Schedule																													197.51							Fee Schedule																																															
CANNULA CLEAR THREADED 214120	272	RC						Both			105	47.25	47.25	94.5	68.25							Fee Schedule		77.7							Fee Schedule																													94.5							Fee Schedule																																															
CANNULA KIT WITH OBTURATOR	272	RC						Both			44.1	19.85	19.85	39.69	28.67							Fee Schedule		32.63							Fee Schedule																													39.69							Fee Schedule																																															
CANNULA SEAL	272	RC						Both			50.4	22.68	22.68	45.36	32.76							Fee Schedule		37.3							Fee Schedule																													45.36							Fee Schedule																																															
CANNULATED BONE SCREW	278	RC	C1713	CPT				Both			384.3	172.94	172.94	345.87		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	284.38							Fee Schedule																													345.87							Fee Schedule																																															
CANNULATED BONE SCREW 6.5 LONG	278	RC	C1713	CPT				Both			74.55	33.55	33.55	67.1		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	55.17							Fee Schedule																													67.1							Fee Schedule																																															
CANNULATED INTERFER SCREW 7X25	278	RC	C1713	CPT				Both			388.5	174.83	174.83	349.65		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	287.49							Fee Schedule																													349.65							Fee Schedule																																															
CANNULATED INTERFERENCE SCREW 8X20	278	RC	C1713	CPT				Both			388.5	174.83	174.83	349.65		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	287.49							Fee Schedule																													349.65							Fee Schedule																																															
CANNULATOME CT 25	272	RC						Both			422.1	189.95	189.95	379.89	274.37							Fee Schedule		312.35							Fee Schedule																													379.89							Fee Schedule																																															
CANVAS ANKLE BRACE LARGE	274	RC	L1906	CPT				Both			21	9.45	9.45	181.61		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	15.54							Fee Schedule		162.66							Fee Schedule		110.34							Fee Schedule		157.92							Fee Schedule		18.9							Fee Schedule		181.61							Fee Schedule		146.87							Fee Schedule											181.61							Fee Schedule		146.87							Fee Schedule		
CANVAS ANKLE BRACE MEDIUM	274	RC	L1906	CPT				Both			21	9.45	9.45	181.61		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	15.54							Fee Schedule		162.66							Fee Schedule		110.34							Fee Schedule		157.92							Fee Schedule		18.9							Fee Schedule		181.61							Fee Schedule		146.87							Fee Schedule											181.61							Fee Schedule		146.87							Fee Schedule		
CANVAS ANKLE BRACE SMALL	274	RC	L1906	CPT				Both			21	9.45	9.45	181.61		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	15.54							Fee Schedule		162.66							Fee Schedule		110.34							Fee Schedule		157.92							Fee Schedule		18.9							Fee Schedule		181.61							Fee Schedule		146.87							Fee Schedule											181.61							Fee Schedule		146.87							Fee Schedule		
CAPIO CAPTURING DEVICE #M0068318261	272	RC	C2631	CPT				Both			2220	999	846.59	1998	846.59							Fee Schedule		1642.8							Fee Schedule																													1998							Fee Schedule																																															
CAPIO SUTURE #M0068332241	272	RC						Both			193	86.85	86.85	173.7	125.45							Fee Schedule		142.82							Fee Schedule																													173.7							Fee Schedule																																															
CAPSAICIN 0.025% CREAM- 60 GM	250	RC						Both			21.53	9.69	9.69	19.38	13.99							Fee Schedule		15.93							Fee Schedule																													19.38							Fee Schedule																																															
CAPSAICIN CREAM 0.025% 60 GM	250	RC	A9270	CPT				Both			31.5	14.18	0.01	28.35	0.01							Fee Schedule		23.31							Fee Schedule																													28.35							Fee Schedule																																															
CAPTIFLEX MEDIUM OVAL #M00562401	272	RC						Both			41	18.45	18.45	36.9	26.65							Fee Schedule		30.34							Fee Schedule																													36.9							Fee Schedule																																															
CAPTIVATOR COLD SNARE #M00561103	272	RC						Both			41	18.45	18.45	36.9	26.65							Fee Schedule		30.34							Fee Schedule																													36.9							Fee Schedule																																															
CAPTIVATOR HEX SNARE MED #M00562341	272	RC						Both			43	19.35	19.35	38.7	27.95							Fee Schedule		31.82							Fee Schedule																													38.7							Fee Schedule																																															
CAPTOPRIL 12.5 MG  TABLET	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
CAPTOPRIL 12.5MG TABLET UD	250	RC	A9270	CPT				Both			5.25	2.36	0.01	4.73	0.01							Fee Schedule		3.89							Fee Schedule																													4.73							Fee Schedule																																															
CAPTOPRIL 25 MG (CAPOTEN) TABLET	250	RC	A9270	CPT				Both			5.25	2.36	0.01	4.73	0.01							Fee Schedule		3.89							Fee Schedule																													4.73							Fee Schedule																																															
CAR SEAT INFANT	270	RC						Both			214	96.3	96.3	192.6	139.1							Fee Schedule		158.36							Fee Schedule																													192.6							Fee Schedule																																															
CAR SEAT PREEMIE #CS100111198	271	RC						Both			429	193.05	193.05	386.1	278.85							Fee Schedule		317.46							Fee Schedule																													386.1							Fee Schedule																																															
CARBAMAZEPINE (TEGRETOL) QUEST 329	301	RC	80156	CPT				Both			30	13.5	12.95	27	12.95							Fee Schedule		16.18							Fee Schedule		15.01							Fee Schedule		14.57							Fee Schedule		14.57							Fee Schedule		27							Fee Schedule		16.76							Fee Schedule		13.55							Fee Schedule		14.57							Fee Schedule		16.76							Fee Schedule		13.55							Fee Schedule		
carBAMazepine 100 MG  TABLET	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
carBAMazepine 100 MG/5ML SUSP 5ML  UD	250	RC	A9270	CPT				Both			10.88	4.9	0.01	9.79	0.01							Fee Schedule		8.05							Fee Schedule																													9.79							Fee Schedule																																															
carBAMazepine 200 MG TABLET	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
carBAMazepine 200 MG/10ML SUSP	250	RC	A9270	CPT				Both			14.7	6.62	0.01	13.23	0.01							Fee Schedule		10.88							Fee Schedule																													13.23							Fee Schedule																																															
CARBAMAZEPINE XR 100 MG TABLET UD	250	RC	A9270	CPT				Both			1.58	0.71	0.01	1.42	0.01							Fee Schedule		1.17							Fee Schedule																													1.42							Fee Schedule																																															
CARBIDOPA/L-DOPA 10-100 MG TAB	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
CARBIDOPA/L-DOPA 25-100 MG  TAB	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
CARBIDOPA/L-DOPA 25-250 MG TAB	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
CARBIDOPA/L-DOPA ER 25-100MG TAB	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
CARBOCAINE 1.5% 15MG/ML 30 ML VIAL	636	RC	J0670	CPT				Both			46.78	21.05	2.67	42.1		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	34.62							Fee Schedule		4.27							Fee Schedule		2.67							Fee Schedule		4.15							Fee Schedule		42.1							Fee Schedule		4.77							Fee Schedule		3.86							Fee Schedule											4.77							Fee Schedule		3.86							Fee Schedule		
CARBOCAINE 2% 50ML INJECTION VIAL	636	RC	J2001	CPT				Both			12.6	5.67	5.67	11.34		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	9.32							Fee Schedule																													11.34							Fee Schedule																																															
CARBOCAINE:1 % 10 MG/ML 30 ML VIAL	636	RC	J0670	CPT				Both			25.2	11.34	2.67	22.68		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	18.65							Fee Schedule		4.27							Fee Schedule		2.67							Fee Schedule		4.15							Fee Schedule		22.68							Fee Schedule		4.77							Fee Schedule		3.86							Fee Schedule											4.77							Fee Schedule		3.86							Fee Schedule		
CARBOXYHEMOGLOBIN WITH ABG	301	RC	82803	CPT				Both			165.9	74.66	18.77	149.31	18.77							Fee Schedule		26.07							Fee Schedule		26.85							Fee Schedule		26.07							Fee Schedule		26.07							Fee Schedule		149.31							Fee Schedule		29.98							Fee Schedule		24.25							Fee Schedule											29.98							Fee Schedule		24.25							Fee Schedule		
CARDENE 20 MG CAPSULE UD	250	RC	A9270	CPT				Both			5.25	2.36	0.01	4.73	0.01							Fee Schedule		3.89							Fee Schedule																													4.73							Fee Schedule																																															
CARDENE 30 MG (NICARDIPINE) CAPSULE	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
CARDENE SR 30MG CAPSULE	250	RC	A9270	CPT				Both			4.2	1.89	0.01	3.78	0.01							Fee Schedule		3.11							Fee Schedule																													3.78							Fee Schedule																																															
CARDENE SR 45MG CAP	250	RC	A9270	CPT				Both			4.2	1.89	0.01	3.78	0.01							Fee Schedule		3.11							Fee Schedule																													3.78							Fee Schedule																																															
PULMONARY EMBOLISM WITH MCC OR ACUTE COR PULMONALE					175	DRG		Inpatient			28397.56	12778.9	12778.9	12778.9							0		No services performed during 15 month lookback period. 				15207.26	3326.98	27087.53	1 through 10									0		No services performed during 15 month lookback period				3169.78	3169.78	3169.78	1 through 10						8144.95	8144.95	8144.95	1 through 10									0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period				4839.45	4839.45	4839.45	1 through 10									0		No services provided during 15 month lookback							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period	
PULMONARY EMBOLISM WITHOUT MCC					176	DRG		Inpatient			31759.4	14291.73	14291.73	14291.73				26068.38	26068.38	26068.38	1 through 10									0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period				2966.52	2966.52	2966.52	1 through 10									0		No services provided during 15 month lookback							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period	
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH MCC					177	DRG		Inpatient			34243.73	15409.68	15409.68	15409.68							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period. 				12278.65	1227.87	11050.79	1 through 10						481.27	481.27	481.27	1 through 10						11902.94	11902.94	11902.94	1 through 10									0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period				6110.99	6110.99	6110.99	1 through 10									0		No services provided during 15 month lookback				11182.44	11182.44	11182.44	1 through 10									0		No services provided during 15 month lookback period	
CARDIAC MONITOR	730	RC	93041	CPT				Both			116.55	52.45	4.37	286	4.95							Fee Schedule		86.25							Fee Schedule											4.37							Fee Schedule											104.9							Fee Schedule																				286							Per Diem																				
CARDINAL VASCULAR CLOSURE DEVICE MX6760	278	RC	C1760	CPT				Both			853	383.85	383.85	767.7		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	631.22							Fee Schedule																													767.7							Fee Schedule																																															
CARDIO CRP CRPH SERUM PLASMA	302	RC	86140	CPT				Both			85.05	38.27	4.6	76.55	4.6							Fee Schedule		5.75							Fee Schedule		5.34							Fee Schedule		5.18							Fee Schedule		5.18							Fee Schedule		76.55							Fee Schedule		5.96							Fee Schedule		4.82							Fee Schedule		5.18							Fee Schedule		5.96							Fee Schedule		4.82							Fee Schedule		
CARDIO IQ CYP2C19 GENOTYPE 90668	302	RC	81225	CPT				Both			1217.46	547.86	209.78	1095.71	209.78							Fee Schedule		291.36							Fee Schedule		300.1							Fee Schedule		291.36							Fee Schedule		291.36							Fee Schedule		1095.71							Fee Schedule		335.06							Fee Schedule		270.96							Fee Schedule		291.36							Fee Schedule		335.06							Fee Schedule		270.96							Fee Schedule		
CARDIO IQ LIPOPROTEIN FRACTIONATION	301	RC	83704	CPT				Both			136.35	61.36	28.04	122.72	28.04							Fee Schedule		35.06							Fee Schedule		35.22							Fee Schedule		34.19							Fee Schedule		34.19							Fee Schedule		122.72							Fee Schedule		39.32							Fee Schedule		31.8							Fee Schedule		34.19							Fee Schedule		39.32							Fee Schedule		31.8							Fee Schedule		
CARDIO JADE PTA BALLOON 596024022	272	RC	C1725	CPT				Both			600	270	93.3	540	93.3							Fee Schedule		444							Fee Schedule																													540							Fee Schedule																																															
CARDIOLIPIN AB 7352 BLUE TOP TUBE RT	302	RC	86147	CPT				Both			112.35	50.56	22.62	101.12	22.62							Fee Schedule		28.28							Fee Schedule		26.21							Fee Schedule		25.45							Fee Schedule		25.45							Fee Schedule		101.12							Fee Schedule		29.27							Fee Schedule		23.67							Fee Schedule		25.45							Fee Schedule		29.27							Fee Schedule		23.67							Fee Schedule		
CARDIOLIPIN AB IGA 4661 LIGHT BLUE TUBE	302	RC	86147	CPT				Both			95.55	43	22.62	86	22.62							Fee Schedule		28.28							Fee Schedule		26.21							Fee Schedule		25.45							Fee Schedule		25.45							Fee Schedule		86							Fee Schedule		29.27							Fee Schedule		23.67							Fee Schedule		25.45							Fee Schedule		29.27							Fee Schedule		23.67							Fee Schedule		
CARDIOLIPIN AB IGG 4662 LIGHT BLUE TUBE	302	RC	86147	CPT				Both			95.55	43	22.62	86	22.62							Fee Schedule		28.28							Fee Schedule		26.21							Fee Schedule		25.45							Fee Schedule		25.45							Fee Schedule		86							Fee Schedule		29.27							Fee Schedule		23.67							Fee Schedule		25.45							Fee Schedule		29.27							Fee Schedule		23.67							Fee Schedule		
CARDIOLIPIN AB IGM 4663 LIGHT BLUE TUBE	302	RC	86147	CPT				Both			95.55	43	22.62	86	22.62							Fee Schedule		28.28							Fee Schedule		26.21							Fee Schedule		25.45							Fee Schedule		25.45							Fee Schedule		86							Fee Schedule		29.27							Fee Schedule		23.67							Fee Schedule		25.45							Fee Schedule		29.27							Fee Schedule		23.67							Fee Schedule		
CARDIOLIPIN ANTIBODY	302	RC	86318	CPT				Both			120.75	54.34	13.02	108.68	13.02							Fee Schedule		18.09							Fee Schedule		18.63							Fee Schedule		18.09							Fee Schedule		18.09							Fee Schedule		108.68							Fee Schedule		20.8							Fee Schedule		16.82							Fee Schedule		18.09							Fee Schedule		20.8							Fee Schedule		16.82							Fee Schedule		
CARDIOVASC. CLASSIC OAS DBP-150CLASS145	272	RC	C1724	CPT				Both			10785	4853.25	525.82	9706.5	525.82							Fee Schedule		7980.9							Fee Schedule																													9706.5							Fee Schedule																																															
CARDIOVASC. CLASSIC OAS DBP-200CLASS145	272	RC	C1724	CPT				Both			10785	4853.25	525.82	9706.5	525.82							Fee Schedule		7980.9							Fee Schedule																													9706.5							Fee Schedule																																															
CARDIOVASC. SOLID OAS DBP-150SOLID145	272	RC	C1724	CPT				Both			10785	4853.25	525.82	9706.5	525.82							Fee Schedule		7980.9							Fee Schedule																													9706.5							Fee Schedule																																															
CARDIOVASC. SOLID OAS DBP-200SOLID145	272	RC	C1724	CPT				Both			10785	4853.25	525.82	9706.5	525.82							Fee Schedule		7980.9							Fee Schedule																													9706.5							Fee Schedule																																															
CARDIOVASC. VIPERWIRE ADVANCE VPR-GW-14	272	RC	C1769	CPT				Both			600	270	154.26	540	154.26							Fee Schedule		444							Fee Schedule																													540							Fee Schedule																																															
CARDIOVASC. VIPERWIRE ADVANCE VPR-GW-17	272	RC	C1769	CPT				Both			600	270	154.26	540	154.26							Fee Schedule		444							Fee Schedule																													540							Fee Schedule																																															
CARDIOVASC. VIPERWIRE ADVANCE VPR-GW-200	272	RC	C1769	CPT				Both			598.5	269.33	154.26	538.65	154.26							Fee Schedule		442.89							Fee Schedule																													538.65							Fee Schedule																																															
CARDIOVASCULAR ASAHI ASAHI PAGH143392	272	RC	C1769	CPT				Both			3071.25	1382.06	154.26	2764.13	154.26							Fee Schedule		2272.73							Fee Schedule																													2764.13							Fee Schedule																																															
CARDIOVASCULAR ASAHI ASTATO PAGH143092	272	RC	C1769	CPT				Both			2992.5	1346.63	154.26	2693.25	154.26							Fee Schedule		2214.45							Fee Schedule																													2693.25							Fee Schedule																																															
CARDIOVASCULAR ASAHI ASTATO PAGH18M071	272	RC	C1769	CPT				Both			2992.5	1346.63	154.26	2693.25	154.26							Fee Schedule		2214.45							Fee Schedule																													2693.25							Fee Schedule																																															
CARDIOVASCULAR ASAHI ASTATO PAGH18M371	272	RC	C1769	CPT				Both			3071.25	1382.06	154.26	2764.13	154.26							Fee Schedule		2272.73							Fee Schedule																													2764.13							Fee Schedule																																															
CARDIOVASCULAR ASAHI FLOPPY PAGH18M072	272	RC	C1769	CPT				Both			2992.5	1346.63	154.26	2693.25	154.26							Fee Schedule		2214.45							Fee Schedule																													2693.25							Fee Schedule																																															
CARDIOVASCULAR ASAHI FLOPPY PAGH18M372	272	RC	C1769	CPT				Both			3071.25	1382.06	154.26	2764.13	154.26							Fee Schedule		2272.73							Fee Schedule																													2764.13							Fee Schedule																																															
CARDIOVASCULAR ASAHI REGALIA PAGP140000	272	RC	C1769	CPT				Both			2992.5	1346.63	154.26	2693.25	154.26							Fee Schedule		2214.45							Fee Schedule																													2693.25							Fee Schedule																																															
CARDIOVASCULAR ASAHI REGALIA PAGP140300	272	RC	C1769	CPT				Both			3071.25	1382.06	154.26	2764.13	154.26							Fee Schedule		2272.73							Fee Schedule																													2764.13							Fee Schedule																																															
CARDIOVASCULAR ASAHI TREASURE PAGH18M070	272	RC	C1769	CPT				Both			2992.5	1346.63	154.26	2693.25	154.26							Fee Schedule		2214.45							Fee Schedule																													2693.25							Fee Schedule																																															
CARDIOVASCULAR ASAHI TREASURE PAGH18M370	272	RC	C1769	CPT				Both			3071.25	1382.06	154.26	2764.13	154.26							Fee Schedule		2272.73							Fee Schedule																													2764.13							Fee Schedule																																															
CARDIOVASCULAR MICRO OAS DBP-125MICRO145	272	RC	C1724	CPT				Both			10785	4853.25	525.82	9706.5	525.82							Fee Schedule		7980.9							Fee Schedule																													9706.5							Fee Schedule																																															
CARDIOVASCULAR MICRO OAS DBP-125MICRO60	272	RC	C1724	CPT				Both			11954.25	5379.41	525.82	10758.83	525.82							Fee Schedule		8846.15							Fee Schedule																													10758.83							Fee Schedule																																															
CARDIOVASCULAR RADIOPAQUE TAPE VPR-TRK20	272	RC						Both			255	114.75	114.75	229.5	165.75							Fee Schedule		188.7							Fee Schedule																													229.5							Fee Schedule																																															
CARDIOVASCULAR SOLID DBP-125SOLID145	272	RC	C1724	CPT				Both			10785	4853.25	525.82	9706.5	525.82							Fee Schedule		7980.9							Fee Schedule																													9706.5							Fee Schedule																																															
CARDIOVASCULAR SOLID OAS DBP-125SOLID60	272	RC	C1724	CPT				Both			11954.25	5379.41	525.82	10758.83	525.82							Fee Schedule		8846.15							Fee Schedule																													10758.83							Fee Schedule																																															
CARISOPRODOL 350MG (SOMA) TABLET	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
CARISOPRODOL SOMA 312	301	RC	80299	CPT				Both			65.1	29.3	13.42	58.59	13.42							Fee Schedule		18.64							Fee Schedule		19.2							Fee Schedule		18.64							Fee Schedule		18.64							Fee Schedule		58.59							Fee Schedule		21.44							Fee Schedule		17.34							Fee Schedule		18.64							Fee Schedule		21.44							Fee Schedule		17.34							Fee Schedule		
CARMOL TEN LOT	250	RC	A9270	CPT				Both			16.13	7.26	0.01	14.52	0.01							Fee Schedule		11.94							Fee Schedule																													14.52							Fee Schedule																																															
CARNITINE 70107 SERUM	301	RC	82379	CPT				Both			105	47.25	15	94.5	15							Fee Schedule		18.74							Fee Schedule		17.38							Fee Schedule		16.87							Fee Schedule		16.87							Fee Schedule		94.5							Fee Schedule		19.4							Fee Schedule		15.69							Fee Schedule		16.87							Fee Schedule		19.4							Fee Schedule		15.69							Fee Schedule		
CAROTENE SERUM 311 (protect from light)	301	RC	82380	CPT				Both			52.5	23.63	8.2	47.25	8.2							Fee Schedule		10.25							Fee Schedule		9.5							Fee Schedule		9.22							Fee Schedule		9.22							Fee Schedule		47.25							Fee Schedule		10.6							Fee Schedule		8.57							Fee Schedule		9.22							Fee Schedule		10.6							Fee Schedule		8.57							Fee Schedule		
CAROTID ARTERY SHUNT KIT  8888577775	272	RC						Both			131	58.95	58.95	117.9	85.15							Fee Schedule		96.94							Fee Schedule																													117.9							Fee Schedule																																															
CARVEDILOL  3.125 MG  TABLET	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
CARVEDILOL  6.25 MG TABLET	250	RC	A9270	CPT				Both			7.35	3.31	0.01	6.62	0.01							Fee Schedule		5.44							Fee Schedule																													6.62							Fee Schedule																																															
CARVEDILOL 12.5 MG TABLET	250	RC	A9270	CPT				Both			7.35	3.31	0.01	6.62	0.01							Fee Schedule		5.44							Fee Schedule																													6.62							Fee Schedule																																															
CASCARA 4 OZ	250	RC	A9270	CPT				Both			9.58	4.31	0.01	8.62	0.01							Fee Schedule		7.09							Fee Schedule																													8.62							Fee Schedule																																															
CASPOFUNGIN 50MG VIAL	636	RC	J0637	CPT				Both			353	158.85	2.68	317.7		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	261.22							Fee Schedule		2.97							Fee Schedule											2.88							Fee Schedule		317.7							Fee Schedule		3.31							Fee Schedule		2.68							Fee Schedule											3.31							Fee Schedule		2.68							Fee Schedule		
CASPOFUNGIN 50MG/NS 250ML IVPB	636	RC	J0637	CPT				Both			365	164.25	2.68	328.5		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	270.1							Fee Schedule		2.97							Fee Schedule											2.88							Fee Schedule		328.5							Fee Schedule		3.31							Fee Schedule		2.68							Fee Schedule											3.31							Fee Schedule		2.68							Fee Schedule		
CASPOFUNGIN 70MG VIAL	636	RC	J0637	CPT				Both			371	166.95	2.68	333.9		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	274.54							Fee Schedule		2.97							Fee Schedule											2.88							Fee Schedule		333.9							Fee Schedule		3.31							Fee Schedule		2.68							Fee Schedule											3.31							Fee Schedule		2.68							Fee Schedule		
CASPOFUNGIN 70MG/NS 250ML IVPB	636	RC	J0637	CPT				Both			384	172.8	2.68	345.6		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	284.16							Fee Schedule		2.97							Fee Schedule											2.88							Fee Schedule		345.6							Fee Schedule		3.31							Fee Schedule		2.68							Fee Schedule											3.31							Fee Schedule		2.68							Fee Schedule		
CAST LONG ARM	274	RC	A4580	CPT				Both			34.65	15.59	15.59	31.19		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	25.64							Fee Schedule											23.72							Fee Schedule											31.19							Fee Schedule																																															
CAST LONG LEG	274	RC	A4580	CPT				Both			71.4	32.13	23.72	64.26		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	52.84							Fee Schedule											23.72							Fee Schedule											64.26							Fee Schedule																																															
CAST PAD 2  WATER RESIST. #7344300	271	RC						Both			16	7.2	7.2	14.4	10.4							Fee Schedule		11.84							Fee Schedule																													14.4							Fee Schedule																																															
CAST PAD 3  WATER RESIST. #7344301	271	RC						Both			18	8.1	8.1	16.2	11.7							Fee Schedule		13.32							Fee Schedule																													16.2							Fee Schedule																																															
CAST PAD 3 #9033  BSN	271	RC						Both			1.58	0.71	0.71	1.42	1.03							Fee Schedule		1.17							Fee Schedule																													1.42							Fee Schedule																																															
CAST PAD 4  WATER RESIST. #7344302	271	RC						Both			20	9	9	18	13							Fee Schedule		14.8							Fee Schedule																													18							Fee Schedule																																															
CAST SHOE LARGE	270	RC						Both			110.25	49.61	49.61	99.23	71.66							Fee Schedule		81.59							Fee Schedule																													99.23							Fee Schedule																																															
CAST SHOE MEDIUM	270	RC						Both			110.25	49.61	49.61	99.23	71.66							Fee Schedule		81.59							Fee Schedule																													99.23							Fee Schedule																																															
CAST SHOE PEDIATRIC	270	RC						Both			72.45	32.6	32.6	65.21	47.09							Fee Schedule		53.61							Fee Schedule																													65.21							Fee Schedule																																															
CAST SHOE SMALL #1995-012	271	RC						Both			110.25	49.61	49.61	99.23	71.66							Fee Schedule		81.59							Fee Schedule																													99.23							Fee Schedule																																															
CASTOR OIL 2 OZ	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
CATECHOLAMINES 314 PLASMA 2 GREEN TOPS	301	RC	82384	CPT				Both			130.2	58.59	22.45	117.18	22.45							Fee Schedule		28.06							Fee Schedule		26.01							Fee Schedule		25.25							Fee Schedule		25.25							Fee Schedule		117.18							Fee Schedule		29.04							Fee Schedule		23.48							Fee Schedule		25.25							Fee Schedule		29.04							Fee Schedule		23.48							Fee Schedule		
CATECHOLAMINES 318 URINE 24 HR FZ	301	RC	82382	CPT				Both			85.05	38.27	19.66	76.55	19.66							Fee Schedule		27.3							Fee Schedule		28.12							Fee Schedule		27.3							Fee Schedule		27.3							Fee Schedule		76.55							Fee Schedule		31.4							Fee Schedule		25.39							Fee Schedule		27.3							Fee Schedule		31.4							Fee Schedule		25.39							Fee Schedule		
CATH 2-WAY 14FR 10CC DYND11591 SILICONE	272	RC	A4340	CPT				Both			36	16.2	16.2	52.04	28.59							Fee Schedule		26.64							Fee Schedule		46.61							Fee Schedule		35.74							Fee Schedule		45.25							Fee Schedule		32.4							Fee Schedule		52.04							Fee Schedule		42.08							Fee Schedule											52.04							Fee Schedule		42.08							Fee Schedule		
CATH 2-WAY 16FR 10CC DYND11592 SILICONE	272	RC	A4340	CPT				Both			38	17.1	17.1	52.04	28.59							Fee Schedule		28.12							Fee Schedule		46.61							Fee Schedule		35.74							Fee Schedule		45.25							Fee Schedule		34.2							Fee Schedule		52.04							Fee Schedule		42.08							Fee Schedule											52.04							Fee Schedule		42.08							Fee Schedule		
CATH 2-WAY 18FR 10CC DYND11593 SILICONE	272	RC	A4340	CPT				Both			40	18	18	52.04	28.59							Fee Schedule		29.6							Fee Schedule		46.61							Fee Schedule		35.74							Fee Schedule		45.25							Fee Schedule		36							Fee Schedule		52.04							Fee Schedule		42.08							Fee Schedule											52.04							Fee Schedule		42.08							Fee Schedule		
CATH 2-WAY 20FR 10CC DYND11594 SILICONE	272	RC	A4340	CPT				Both			39	17.55	17.55	52.04	28.59							Fee Schedule		28.86							Fee Schedule		46.61							Fee Schedule		35.74							Fee Schedule		45.25							Fee Schedule		35.1							Fee Schedule		52.04							Fee Schedule		42.08							Fee Schedule											52.04							Fee Schedule		42.08							Fee Schedule		
CATH BALL TRERCP1NIC	272	RC						Both			118.65	53.39	53.39	106.79	77.12							Fee Schedule		87.8							Fee Schedule																													106.79							Fee Schedule																																															
CATH BULLT TPERCP1BT	272	RC						Both			135.45	60.95	60.95	121.91	88.04							Fee Schedule		100.23							Fee Schedule																													121.91							Fee Schedule																																															
CATH GLO TP/TPR GT1T	272	RC						Both			118.65	53.39	53.39	106.79	77.12							Fee Schedule		87.8							Fee Schedule																													106.79							Fee Schedule																																															
CATH PEEL AWY PLA 1	272	RC						Both			24.15	10.87	10.87	21.74	15.7							Fee Schedule		17.87							Fee Schedule																													21.74							Fee Schedule																																															
CATH TRAY (DISP)W/F	272	RC						Both			63	28.35	28.35	56.7	40.95							Fee Schedule		46.62							Fee Schedule																													56.7							Fee Schedule																																															
CATH TRAY W/O CATH	272	RC						Both			51.69	23.26	23.26	46.52	33.6							Fee Schedule		38.25							Fee Schedule																													46.52							Fee Schedule																																															
CATHALON 20G ER	272	RC						Both			24.15	10.87	10.87	21.74	15.7							Fee Schedule		17.87							Fee Schedule																													21.74							Fee Schedule																																															
CATHALON 22G. X 1  PRESS. INJ.  # 383591	272	RC						Both			16.28	7.33	7.33	14.65	10.58							Fee Schedule		12.05							Fee Schedule																													14.65							Fee Schedule																																															
CATHALON 24 R	272	RC						Both			2.36	1.06	1.06	2.12	1.53							Fee Schedule		1.75							Fee Schedule																													2.12							Fee Schedule																																															
CATHALON P 14	272	RC						Both			6.3	2.84	2.84	5.67	4.1							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
CATHALON P 16	272	RC						Both			6.3	2.84	2.84	5.67	4.1							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
CATHALON P 18	272	RC						Both			5.25	2.36	2.36	4.73	3.41							Fee Schedule		3.89							Fee Schedule																													4.73							Fee Schedule																																															
CATHALON P 20 305606	272	RC						Both			4.62	2.08	2.08	4.16	3							Fee Schedule		3.42							Fee Schedule																													4.16							Fee Schedule																																															
CATHALON P 22 305006	272	RC						Both			5.25	2.36	2.36	4.73	3.41							Fee Schedule		3.89							Fee Schedule																													4.73							Fee Schedule																																															
CATHALON P 24	272	RC						Both			6.3	2.84	2.84	5.67	4.1							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
CATHALON REGULAR 18GX1-1/4 405420	272	RC						Both			6.3	2.84	2.84	5.67	4.1							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
CATHALON REGULAR 20	272	RC						Both			8.4	3.78	3.78	7.56	5.46							Fee Schedule		6.22							Fee Schedule																													7.56							Fee Schedule																																															
CATHALON REGULAR 22	272	RC						Both			8.4	3.78	3.78	7.56	5.46							Fee Schedule		6.22							Fee Schedule																													7.56							Fee Schedule																																															
CATHETER (2 WAY) ALL SIZE	272	RC						Both			22.05	9.92	9.92	19.85	14.33							Fee Schedule		16.32							Fee Schedule																													19.85							Fee Schedule																																															
CATHETER 10FR DOVER 888492025	272	RC						Both			1.05	0.47	0.47	0.95	0.68							Fee Schedule		0.78							Fee Schedule																													0.95							Fee Schedule																																															
CATHETER 14 FR. 5CC 8887605148	272	RC						Both			26	11.7	11.7	23.4	16.9							Fee Schedule		19.24							Fee Schedule																													23.4							Fee Schedule																																															
CATHETER 16FR DOVER 8887605163	272	RC						Both			10.5	4.73	4.73	9.45	6.83							Fee Schedule		7.77							Fee Schedule																													9.45							Fee Schedule																																															
CATHETER 18FR DOVER 8887605189	272	RC						Both			15	6.75	6.75	13.5	9.75							Fee Schedule		11.1							Fee Schedule																													13.5							Fee Schedule																																															
CATHETER 20FR DOVER 8887605205	272	RC						Both			26	11.7	11.7	23.4	16.9							Fee Schedule		19.24							Fee Schedule																													23.4							Fee Schedule																																															
CATHETER 22FR DOVER 8887605221	272	RC						Both			21	9.45	9.45	18.9	13.65							Fee Schedule		15.54							Fee Schedule																													18.9							Fee Schedule																																															
CATHETER 24FR DOVER 8887605247	272	RC						Both			19	8.55	8.55	17.1	12.35							Fee Schedule		14.06							Fee Schedule																													17.1							Fee Schedule																																															
CATHETER 2-WAY 12 FR. 5CC 0168L12 LATEX	272	RC						Both			51	22.95	22.95	45.9	33.15							Fee Schedule		37.74							Fee Schedule																													45.9							Fee Schedule																																															
CATHETER 2-WAY 14FR 30CC 8887624149	272	RC						Both			10	4.5	4.5	9	6.5							Fee Schedule		7.4							Fee Schedule																													9							Fee Schedule																																															
CATHETER 2-WAY 14FR 5CC 0168L14 LATEX	272	RC	A4340	CPT				Both			51	22.95	22.95	52.04	28.59							Fee Schedule		37.74							Fee Schedule		46.61							Fee Schedule		35.74							Fee Schedule		45.25							Fee Schedule		45.9							Fee Schedule		52.04							Fee Schedule		42.08							Fee Schedule											52.04							Fee Schedule		42.08							Fee Schedule		
CATHETER 2-WAY 16FR 5CC 0168L16 LATEX	272	RC	A4340	CPT				Both			27	12.15	12.15	52.04	28.59							Fee Schedule		19.98							Fee Schedule		46.61							Fee Schedule		35.74							Fee Schedule		45.25							Fee Schedule		24.3							Fee Schedule		52.04							Fee Schedule		42.08							Fee Schedule											52.04							Fee Schedule		42.08							Fee Schedule		
CATHETER 2-WAY 18FR 30CC 3607	272	RC						Both			3.15	1.42	1.42	2.84	2.05							Fee Schedule		2.33							Fee Schedule																													2.84							Fee Schedule																																															
CATHETER 2-WAY 18FR 5CC 0168L18 LATEX	272	RC	A4340	CPT				Both			27	12.15	12.15	52.04	28.59							Fee Schedule		19.98							Fee Schedule		46.61							Fee Schedule		35.74							Fee Schedule		45.25							Fee Schedule		24.3							Fee Schedule		52.04							Fee Schedule		42.08							Fee Schedule											52.04							Fee Schedule		42.08							Fee Schedule		
CATHETER 2-WAY 20FR 5CC 0168L20 LATEX	272	RC	A4340	CPT				Both			27	12.15	12.15	52.04	28.59							Fee Schedule		19.98							Fee Schedule		46.61							Fee Schedule		35.74							Fee Schedule		45.25							Fee Schedule		24.3							Fee Schedule		52.04							Fee Schedule		42.08							Fee Schedule											52.04							Fee Schedule		42.08							Fee Schedule		
CATHETER 2-WAY 22FR 5CC 0168L22 LATEX	272	RC	A4340	CPT				Both			51	22.95	22.95	52.04	28.59							Fee Schedule		37.74							Fee Schedule		46.61							Fee Schedule		35.74							Fee Schedule		45.25							Fee Schedule		45.9							Fee Schedule		52.04							Fee Schedule		42.08							Fee Schedule											52.04							Fee Schedule		42.08							Fee Schedule		
CATHETER 2-WAY 24FR  168l24	272	RC						Both			51.45	23.15	23.15	46.31	33.44							Fee Schedule		38.07							Fee Schedule																													46.31							Fee Schedule																																															
CATHETER 2-WAY 24FR 0168L24 LATEX	272	RC						Both			51	22.95	22.95	45.9	33.15							Fee Schedule		37.74							Fee Schedule																													45.9							Fee Schedule																																															
CATHETER 2-WAY 26FR 30CC 3573	272	RC						Both			8.4	3.78	3.78	7.56	5.46							Fee Schedule		6.22							Fee Schedule																													7.56							Fee Schedule																																															
CATHETER 3-WAY 18FR 0167V18S	272	RC						Both			56.7	25.52	25.52	51.03	36.86							Fee Schedule		41.96							Fee Schedule																													51.03							Fee Schedule																																															
CATHETER 3-WAY 20FR 0167L20	272	RC						Both			55	24.75	24.75	49.5	35.75							Fee Schedule		40.7							Fee Schedule																													49.5							Fee Schedule																																															
CATHETER 3-WAY 22FR 0167L22	272	RC						Both			38	17.1	17.1	34.2	24.7							Fee Schedule		28.12							Fee Schedule																													34.2							Fee Schedule																																															
CATHETER 3-WAY 24FR 0167L24	272	RC						Both			38	17.1	17.1	34.2	24.7							Fee Schedule		28.12							Fee Schedule																													34.2							Fee Schedule																																															
CATHETER 3-WAY 26FR	272	RC						Both			45.15	20.32	20.32	40.64	29.35							Fee Schedule		33.41							Fee Schedule																													40.64							Fee Schedule																																															
CATHETER 3-WAY16FR 0167L16	272	RC						Both			55	24.75	24.75	49.5	35.75							Fee Schedule		40.7							Fee Schedule																													49.5							Fee Schedule																																															
CATHETER 3-WAY18FR 0167L18	272	RC						Both			55	24.75	24.75	49.5	35.75							Fee Schedule		40.7							Fee Schedule																													49.5							Fee Schedule																																															
CATHETER 6 FR. BARD #135006	272	RC						Both			38.85	17.48	17.48	34.97	25.25							Fee Schedule		28.75							Fee Schedule																													34.97							Fee Schedule																																															
CATHETER ADAPTER #DYND2219	272	RC						Both			2	0.9	0.9	1.8	1.3							Fee Schedule		1.48							Fee Schedule																													1.8							Fee Schedule																																															
CATHETER BARD 10FR.LATEX  0094100	272	RC						Both			2.1	0.95	0.95	1.89	1.37							Fee Schedule		1.55							Fee Schedule																													1.89							Fee Schedule																																															
CATHETER PASSER 36CM 82-1515 INSPIRE	272	RC						Both			798	359.1	359.1	718.2	518.7							Fee Schedule		590.52							Fee Schedule																													718.2							Fee Schedule																																															
CATHETER PASSER 60CM DISP. 48409 INSPIRE	272	RC						Both			708	318.6	318.6	637.2	460.2							Fee Schedule		523.92							Fee Schedule																													637.2							Fee Schedule																																															
CATHETER PLUG 0414L (BD MED)	270	RC						Both			4	1.8	1.8	3.6	2.6							Fee Schedule		2.96							Fee Schedule																													3.6							Fee Schedule																																															
CATHETER SECURE #30-1002	272	RC	A4333	CPT				Both			3	1.35	1.35	3.63	1.99							Fee Schedule		2.22							Fee Schedule		3.25							Fee Schedule											3.16							Fee Schedule		2.7							Fee Schedule		3.63							Fee Schedule		2.94							Fee Schedule											3.63							Fee Schedule		2.94							Fee Schedule		
CATHETER W/GLOVE #DYND41472	272	RC	A4624	CPT				Both			6	2.7	1.46	5.4	2.02							Fee Schedule		4.44							Fee Schedule		3.3							Fee Schedule		1.46							Fee Schedule		3.2							Fee Schedule		5.4							Fee Schedule		3.68							Fee Schedule		2.98							Fee Schedule											3.68							Fee Schedule		2.98							Fee Schedule		
CATHFLO 10MG/100ML NS	250	RC	J2997	CPT				Both			578.55	260.35	87.26	520.7	87.85							Fee Schedule		95.09							Fee Schedule		96.65							Fee Schedule											93.83							Fee Schedule		520.7							Fee Schedule		107.91							Fee Schedule		87.26							Fee Schedule											107.91							Fee Schedule		87.26							Fee Schedule		
CATHFLO 2 MG VIAL (TPA)	636	RC	J2997	CPT				Both			350.6	157.77	87.26	315.54		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	95.09							Fee Schedule		96.65							Fee Schedule											93.83							Fee Schedule		315.54							Fee Schedule		107.91							Fee Schedule		87.26							Fee Schedule											107.91							Fee Schedule		87.26							Fee Schedule		
CAUDE A CATHETER	272	RC						Both			35.7	16.07	16.07	32.13	23.21							Fee Schedule		26.42							Fee Schedule																													32.13							Fee Schedule																																															
CAUTERY DISPOSABLE FINE TIP(ER)	272	RC						Both			59.85	26.93	26.93	53.87	38.9							Fee Schedule		44.29							Fee Schedule																													53.87							Fee Schedule																																															
CAUTERY HIGH TEMP FINE TIP #AA01 (SENECA	272	RC						Both			26	11.7	11.7	23.4	16.9							Fee Schedule		19.24							Fee Schedule																													23.4							Fee Schedule																																															
CAVIERY TIP POLISHER 31142790	272	RC						Both			2	0.9	0.9	1.8	1.3							Fee Schedule		1.48							Fee Schedule																													1.8							Fee Schedule																																															
CBC NO DIFF	305	RC	85027	CPT				Both			117.6	52.92	5.75	105.84	5.75							Fee Schedule		7.18							Fee Schedule		6.66							Fee Schedule		6.47							Fee Schedule		6.47							Fee Schedule		105.84							Fee Schedule		7.44							Fee Schedule		6.02							Fee Schedule		6.47							Fee Schedule		7.44							Fee Schedule		6.02							Fee Schedule		
CBC W AUTO DIFF	305	RC	85025	CPT				Both			124.95	56.23	6.9	112.46	6.9							Fee Schedule		8.63							Fee Schedule		8							Fee Schedule		7.77							Fee Schedule		7.77							Fee Schedule		112.46							Fee Schedule		8.94							Fee Schedule		7.23							Fee Schedule		7.77							Fee Schedule		8.94							Fee Schedule		7.23							Fee Schedule		
CBC W MANUAL DIFF	305	RC	85027	CPT				Both			109.2	49.14	5.75	98.28	5.75							Fee Schedule		7.18							Fee Schedule		6.66							Fee Schedule		6.47							Fee Schedule		6.47							Fee Schedule		98.28							Fee Schedule		7.44							Fee Schedule		6.02							Fee Schedule		6.47							Fee Schedule		7.44							Fee Schedule		6.02							Fee Schedule		
CCTA W/WO CONTRAST NO CALC SCORING	359	RC	75572	CPT				Both			2100	945	128.41	2478	956							Per Diem		163.71							Fee Schedule											128.41							Fee Schedule											1890							Fee Schedule																				2478							Case Rate																				
CCTA W/WO CONTRAST W CALC SCORING	359	RC	75574	CPT				Both			2100	945	248.97	2478	956							Per Diem		248.97							Fee Schedule											335.08							Fee Schedule											1890							Fee Schedule																				2478							Case Rate																				
CEA   QUEST 978	301	RC	82378	CPT				Both			119	53.55	16.86	107.1	16.86							Fee Schedule		21.07							Fee Schedule		19.53							Fee Schedule		18.96							Fee Schedule		18.96							Fee Schedule		107.1							Fee Schedule		21.8							Fee Schedule		17.63							Fee Schedule		18.96							Fee Schedule		21.8							Fee Schedule		17.63							Fee Schedule		
CECLOR SUSP 375MG/5ML-50ML	250	RC	A9270	CPT				Both			77.21	34.74	0.01	69.49	0.01							Fee Schedule		57.14							Fee Schedule																													69.49							Fee Schedule																																															
CEFACLOR 125 MG/5ML ORAL SUSP-75ML	250	RC	A9270	CPT				Both			49.35	22.21	0.01	44.42	0.01							Fee Schedule		36.52							Fee Schedule																													44.42							Fee Schedule																																															
CEFACLOR 250 MG  CAPSULE	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
CEFACLOR 250 MG/5ML ORAL SUSP- 150ML	250	RC	A9270	CPT				Both			89.25	40.16	0.01	80.33	0.01							Fee Schedule		66.05							Fee Schedule																													80.33							Fee Schedule																																															
CEFACLOR 500 MG (CECLOR) CAPSULE	250	RC	A9270	CPT				Both			12.6	5.67	0.01	11.34	0.01							Fee Schedule		9.32							Fee Schedule																													11.34							Fee Schedule																																															
CEFADROXIL 250 MG/5ML ORAL SUSP- 100ML	250	RC	A9270	CPT				Both			76.65	34.49	0.01	68.99	0.01							Fee Schedule		56.72							Fee Schedule																													68.99							Fee Schedule																																															
CEFADROXIL 500 MG CAPSULE UD	250	RC	A9270	CPT				Both			11.55	5.2	0.01	10.4	0.01							Fee Schedule		8.55							Fee Schedule																													10.4							Fee Schedule																																															
CEFAZOLIN 1 GM  VIAL	636	RC	J0690	CPT				Both			12.6	5.67	0.74	11.34		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	9.32							Fee Schedule		0.82							Fee Schedule		3.62							Fee Schedule		0.8							Fee Schedule		11.34							Fee Schedule		0.92							Fee Schedule		0.74							Fee Schedule											0.92							Fee Schedule		0.74							Fee Schedule		
CEFAZOLIN 1GM PREMIX	636	RC	J0690	CPT				Both			34.65	15.59	0.74	31.19		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	25.64							Fee Schedule		0.82							Fee Schedule		3.62							Fee Schedule		0.8							Fee Schedule		31.19							Fee Schedule		0.92							Fee Schedule		0.74							Fee Schedule											0.92							Fee Schedule		0.74							Fee Schedule		
CEFAZOLIN 1GM/D5W 50 ML PREMIX IVPB	250	RC	J0690	CPT				Both			16.8	7.56	0.74	15.12	0.82							Fee Schedule		12.43							Fee Schedule		0.82							Fee Schedule		3.62							Fee Schedule		0.8							Fee Schedule		15.12							Fee Schedule		0.92							Fee Schedule		0.74							Fee Schedule											0.92							Fee Schedule		0.74							Fee Schedule		
CEFAZOLIN 1GM/NS 100ML	636	RC	J0690	CPT				Both			26.82	12.07	0.74	24.14		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	19.85							Fee Schedule		0.82							Fee Schedule		3.62							Fee Schedule		0.8							Fee Schedule		24.14							Fee Schedule		0.92							Fee Schedule		0.74							Fee Schedule											0.92							Fee Schedule		0.74							Fee Schedule		
CEFAZOLIN 2 GM  VIAL	636	RC	J0690	CPT				Both			21.94	9.87	0.74	19.75		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	16.24							Fee Schedule		0.82							Fee Schedule		3.62							Fee Schedule		0.8							Fee Schedule		19.75							Fee Schedule		0.92							Fee Schedule		0.74							Fee Schedule											0.92							Fee Schedule		0.74							Fee Schedule		
CEFAZOLIN 2GM PREMIX	250	RC	J0690	CPT				Both			43.05	19.37	0.74	38.75	0.82							Fee Schedule		31.86							Fee Schedule		0.82							Fee Schedule		3.62							Fee Schedule		0.8							Fee Schedule		38.75							Fee Schedule		0.92							Fee Schedule		0.74							Fee Schedule											0.92							Fee Schedule		0.74							Fee Schedule		
CEFAZOLIN 2GM/100ML NS IVPB	636	RC	J0690	CPT				Both			28.35	12.76	0.74	25.52		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	20.98							Fee Schedule		0.82							Fee Schedule		3.62							Fee Schedule		0.8							Fee Schedule		25.52							Fee Schedule		0.92							Fee Schedule		0.74							Fee Schedule											0.92							Fee Schedule		0.74							Fee Schedule		
CEFAZOLIN 2GM/NS 100ML	636	RC	J0690	CPT				Both			26.82	12.07	0.74	24.14		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	19.85							Fee Schedule		0.82							Fee Schedule		3.62							Fee Schedule		0.8							Fee Schedule		24.14							Fee Schedule		0.92							Fee Schedule		0.74							Fee Schedule											0.92							Fee Schedule		0.74							Fee Schedule		
CEFAZOLIN 500 MG VIAL	636	RC	J0690	CPT				Both			12	5.4	0.74	10.8		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	8.88							Fee Schedule		0.82							Fee Schedule		3.62							Fee Schedule		0.8							Fee Schedule		10.8							Fee Schedule		0.92							Fee Schedule		0.74							Fee Schedule											0.92							Fee Schedule		0.74							Fee Schedule		
CEFDINIR 125 MG/5ML OS (OMNICEF)-60ML	250	RC	A9270	CPT				Both			254.1	114.35	0.01	228.69	0.01							Fee Schedule		188.03							Fee Schedule																													228.69							Fee Schedule																																															
CEFDINIR 250 MG/5ML ORAL SUSPENSION-60ML	250	RC	A9270	CPT				Both			342.3	154.04	0.01	308.07	0.01							Fee Schedule		253.3							Fee Schedule																													308.07							Fee Schedule																																															
CEFDINIR 300MG (OMNICEF) CAPSULE	250	RC	A9270	CPT				Both			17.85	8.03	0.01	16.07	0.01							Fee Schedule		13.21							Fee Schedule																													16.07							Fee Schedule																																															
CEFDINIR 300MG (OMNICEF) CAPSULE	250	RC	A9270	CPT				Both			17.85	8.03	0.01	16.07	0.01							Fee Schedule		13.21							Fee Schedule																													16.07							Fee Schedule																																															
CEFEPIME 1GM PREMIX	636	RC	J0692	CPT				Both			68.76	30.94	1.21	61.88		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	50.88							Fee Schedule		1.33							Fee Schedule											1.3							Fee Schedule		61.88							Fee Schedule		1.49							Fee Schedule		1.21							Fee Schedule											1.49							Fee Schedule		1.21							Fee Schedule		
CEFEPIME 1GM VIAL	636	RC	J0692	CPT				Both			60.99	27.45	1.21	54.89		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	45.13							Fee Schedule		1.33							Fee Schedule											1.3							Fee Schedule		54.89							Fee Schedule		1.49							Fee Schedule		1.21							Fee Schedule											1.49							Fee Schedule		1.21							Fee Schedule		
CEFEPIME 2GM PREMIX	636	RC	J0692	CPT				Both			128.85	57.98	1.21	115.97		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	95.35							Fee Schedule		1.33							Fee Schedule											1.3							Fee Schedule		115.97							Fee Schedule		1.49							Fee Schedule		1.21							Fee Schedule											1.49							Fee Schedule		1.21							Fee Schedule		
CEFEPIME 2GM VIAL	636	RC	J0692	CPT				Both			36	16.2	1.21	32.4		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	26.64							Fee Schedule		1.33							Fee Schedule											1.3							Fee Schedule		32.4							Fee Schedule		1.49							Fee Schedule		1.21							Fee Schedule											1.49							Fee Schedule		1.21							Fee Schedule		
CEFIPIME 1 GM/10 ML INJECTION	250	RC	J0692	CPT				Both			69.3	31.19	1.21	62.37	1.78							Fee Schedule		51.28							Fee Schedule		1.33							Fee Schedule											1.3							Fee Schedule		62.37							Fee Schedule		1.49							Fee Schedule		1.21							Fee Schedule											1.49							Fee Schedule		1.21							Fee Schedule		
CEFIPIME 2 GM/10ML INJECITON	250	RC	J0692	CPT				Both			105	47.25	1.21	94.5	1.78							Fee Schedule		77.7							Fee Schedule		1.33							Fee Schedule											1.3							Fee Schedule		94.5							Fee Schedule		1.49							Fee Schedule		1.21							Fee Schedule											1.49							Fee Schedule		1.21							Fee Schedule		
CEFOTAXIME  1 GM/ NS  (CLAFORAN) IVPB	636	RC	J0698	CPT				Both			21	9.45	9.45	18.9		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	15.54							Fee Schedule											14.83							Fee Schedule											18.9							Fee Schedule																																															
CEFOTAXIME (CLAFORAN) 1 GM VIAL	636	RC	J0698	CPT				Both			21	9.45	9.45	18.9		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	15.54							Fee Schedule											14.83							Fee Schedule											18.9							Fee Schedule																																															
CEFOTAXIME 1 GM (CLAFORAN) VIAL SOLUSET	636	RC	J0698	CPT				Both			21	9.45	9.45	18.9		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	15.54							Fee Schedule											14.83							Fee Schedule											18.9							Fee Schedule																																															
CEFOXITIN 1 GM (MEFOXIN) VIAL	636	RC	J0694	CPT				Both			35.7	16.07	3.99	32.13		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	26.42							Fee Schedule		4.41							Fee Schedule		15.01							Fee Schedule		4.29							Fee Schedule		32.13							Fee Schedule		4.93							Fee Schedule		3.99							Fee Schedule											4.93							Fee Schedule		3.99							Fee Schedule		
CEFOXITIN 1 GM(MEFOXIN) PREMIX	636	RC	J0694	CPT				Both			43.05	19.37	3.99	38.75		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	31.86							Fee Schedule		4.41							Fee Schedule		15.01							Fee Schedule		4.29							Fee Schedule		38.75							Fee Schedule		4.93							Fee Schedule		3.99							Fee Schedule											4.93							Fee Schedule		3.99							Fee Schedule		
CEFOXITIN 1 GM/ NS 100 ML (MEFOXIN) IVPB	636	RC	J0694	CPT				Both			35.37	15.92	3.99	31.83		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	26.17							Fee Schedule		4.41							Fee Schedule		15.01							Fee Schedule		4.29							Fee Schedule		31.83							Fee Schedule		4.93							Fee Schedule		3.99							Fee Schedule											4.93							Fee Schedule		3.99							Fee Schedule		
CEFOXITIN 1GM/NS 100ML	636	RC	J0694	CPT				Both			46.05	20.72	3.99	41.45		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	34.08							Fee Schedule		4.41							Fee Schedule		15.01							Fee Schedule		4.29							Fee Schedule		41.45							Fee Schedule		4.93							Fee Schedule		3.99							Fee Schedule											4.93							Fee Schedule		3.99							Fee Schedule		
CEFOXITIN 2 GM  (MEFOXIN) PREMIX	636	RC	J0694	CPT				Both			77.7	34.97	3.99	69.93		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	57.5							Fee Schedule		4.41							Fee Schedule		15.01							Fee Schedule		4.29							Fee Schedule		69.93							Fee Schedule		4.93							Fee Schedule		3.99							Fee Schedule											4.93							Fee Schedule		3.99							Fee Schedule		
CEFOXITIN 2 GM (MEFOXIN) VIAL	636	RC	J0694	CPT				Both			45.15	20.32	3.99	40.64		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	33.41							Fee Schedule		4.41							Fee Schedule		15.01							Fee Schedule		4.29							Fee Schedule		40.64							Fee Schedule		4.93							Fee Schedule		3.99							Fee Schedule											4.93							Fee Schedule		3.99							Fee Schedule		
CEFOXITIN 2 GM/100 ML NS (MEFOXIN) IVPB	636	RC	J0694	CPT				Both			70.88	31.9	3.99	63.79		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	52.45							Fee Schedule		4.41							Fee Schedule		15.01							Fee Schedule		4.29							Fee Schedule		63.79							Fee Schedule		4.93							Fee Schedule		3.99							Fee Schedule											4.93							Fee Schedule		3.99							Fee Schedule		
CEFOXITIN 2GM/NS 100ML	636	RC	J0694	CPT				Both			56.88	25.6	3.99	51.19		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	42.09							Fee Schedule		4.41							Fee Schedule		15.01							Fee Schedule		4.29							Fee Schedule		51.19							Fee Schedule		4.93							Fee Schedule		3.99							Fee Schedule											4.93							Fee Schedule		3.99							Fee Schedule		
CEFTAZIDIME 1 GM/NS 100 ML (FORTAZ) IVPB	636	RC	J0713	CPT				Both			22.05	9.92	1.34	19.85		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	16.32							Fee Schedule		1.49							Fee Schedule		9.52							Fee Schedule		1.44							Fee Schedule		19.85							Fee Schedule		1.66							Fee Schedule		1.34							Fee Schedule											1.66							Fee Schedule		1.34							Fee Schedule		
CEFTAZIDIME 1 GRAM (FORTAZ) VIAL	636	RC	J0713	CPT				Both			16.8	7.56	1.34	15.12		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	12.43							Fee Schedule		1.49							Fee Schedule		9.52							Fee Schedule		1.44							Fee Schedule		15.12							Fee Schedule		1.66							Fee Schedule		1.34							Fee Schedule											1.66							Fee Schedule		1.34							Fee Schedule		
CEFTAZIDIME 2 GM (FORTAZ) VIAL	636	RC	J0713	CPT				Both			97.65	43.94	1.34	87.89		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	72.26							Fee Schedule		1.49							Fee Schedule		9.52							Fee Schedule		1.44							Fee Schedule		87.89							Fee Schedule		1.66							Fee Schedule		1.34							Fee Schedule											1.66							Fee Schedule		1.34							Fee Schedule		
CEFTIBUTEN 400 MG CAPSULE UD	250	RC	A9270	CPT				Both			19.47	8.76	0.01	17.52	0.01							Fee Schedule		14.41							Fee Schedule																													17.52							Fee Schedule																																															
CEFTIN 125 MG/5ML ORAL SUSP-100 ML	250	RC	A9270	CPT				Both			166.95	75.13	0.01	150.26	0.01							Fee Schedule		123.54							Fee Schedule																													150.26							Fee Schedule																																															
CEFTRIAXONE  1GM PREMIX (ROCEPHIN)	636	RC	J0696	CPT				Both			64.05	28.82	0.38	57.65		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	47.4							Fee Schedule		0.42							Fee Schedule											0.4							Fee Schedule		57.65							Fee Schedule		0.46							Fee Schedule		0.38							Fee Schedule											0.46							Fee Schedule		0.38							Fee Schedule		
CEFTRIAXONE 1GM(ROCEPHIN) VIAL	636	RC	J0696	CPT				Both			12.6	5.67	0.38	11.34		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	9.32							Fee Schedule		0.42							Fee Schedule											0.4							Fee Schedule		11.34							Fee Schedule		0.46							Fee Schedule		0.38							Fee Schedule											0.46							Fee Schedule		0.38							Fee Schedule		
CEFTRIAXONE 1GM(SOLUSET/SYR PUMP) VIAL	636	RC	J0696	CPT				Both			144.9	65.21	0.38	130.41		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	107.23							Fee Schedule		0.42							Fee Schedule											0.4							Fee Schedule		130.41							Fee Schedule		0.46							Fee Schedule		0.38							Fee Schedule											0.46							Fee Schedule		0.38							Fee Schedule		
CEFTRIAXONE 1GM/D5W 50 ML PREMIX IVPB	250	RC	J0696	CPT				Both			44.1	19.85	0.38	39.69	0.6							Fee Schedule		32.63							Fee Schedule		0.42							Fee Schedule											0.4							Fee Schedule		39.69							Fee Schedule		0.46							Fee Schedule		0.38							Fee Schedule											0.46							Fee Schedule		0.38							Fee Schedule		
CEFTRIAXONE 1GM/NS 100ML	636	RC	J0696	CPT				Both			28.08	12.64	0.38	25.27		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	20.78							Fee Schedule		0.42							Fee Schedule											0.4							Fee Schedule		25.27							Fee Schedule		0.46							Fee Schedule		0.38							Fee Schedule											0.46							Fee Schedule		0.38							Fee Schedule		
CEFTRIAXONE 2 GM  (ROCEPHIN) PREMIX	636	RC	J0696	CPT				Both			69.3	31.19	0.38	62.37		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	51.28							Fee Schedule		0.42							Fee Schedule											0.4							Fee Schedule		62.37							Fee Schedule		0.46							Fee Schedule		0.38							Fee Schedule											0.46							Fee Schedule		0.38							Fee Schedule		
CEFTRIAXONE 2 GM (ROCEPHIN) VIAL	636	RC	J0696	CPT				Both			14.7	6.62	0.38	13.23		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	10.88							Fee Schedule		0.42							Fee Schedule											0.4							Fee Schedule		13.23							Fee Schedule		0.46							Fee Schedule		0.38							Fee Schedule											0.46							Fee Schedule		0.38							Fee Schedule		
CEFTRIAXONE 250MG VIAL (SOLUSET)	250	RC	J0696	CPT				Both			85.05	38.27	0.38	76.55	0.6							Fee Schedule		62.94							Fee Schedule		0.42							Fee Schedule											0.4							Fee Schedule		76.55							Fee Schedule		0.46							Fee Schedule		0.38							Fee Schedule											0.46							Fee Schedule		0.38							Fee Schedule		
CEFTRIAXONE 2GM/D5W 50 ML PREMIX IVPB	250	RC						Both			69.3	31.19	31.19	62.37	45.05							Fee Schedule		51.28							Fee Schedule																													62.37							Fee Schedule																																															
CEFTRIAXONE 2GM/NS 100ML	636	RC	J0696	CPT				Both			31.29	14.08	0.38	28.16		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	23.15							Fee Schedule		0.42							Fee Schedule											0.4							Fee Schedule		28.16							Fee Schedule		0.46							Fee Schedule		0.38							Fee Schedule											0.46							Fee Schedule		0.38							Fee Schedule		
CEFTRIAXONE 500 MG (ROCEPHIN) VIAL	636	RC	J0696	CPT				Both			24.15	10.87	0.38	21.74		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	17.87							Fee Schedule		0.42							Fee Schedule											0.4							Fee Schedule		21.74							Fee Schedule		0.46							Fee Schedule		0.38							Fee Schedule											0.46							Fee Schedule		0.38							Fee Schedule		
CEFTRIAXONE 500 MG VIAL(SOLUSET)	636	RC	J0696	CPT				Both			85.05	38.27	0.38	76.55		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	62.94							Fee Schedule		0.42							Fee Schedule											0.4							Fee Schedule		76.55							Fee Schedule		0.46							Fee Schedule		0.38							Fee Schedule											0.46							Fee Schedule		0.38							Fee Schedule		
CEFTRIAXONE 500 MG/NS 100ML	636	RC	J0696	CPT				Both			101.52	45.68	0.38	91.37		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	75.12							Fee Schedule		0.42							Fee Schedule											0.4							Fee Schedule		91.37							Fee Schedule		0.46							Fee Schedule		0.38							Fee Schedule											0.46							Fee Schedule		0.38							Fee Schedule		
CEFUROXIME 250MG (CEFTIN) TABLET	250	RC	A9270	CPT				Both			17.85	8.03	0.01	16.07	0.01							Fee Schedule		13.21							Fee Schedule																													16.07							Fee Schedule																																															
CEFZIL 250 MG TABLET UD	250	RC	A9270	CPT				Both			9.16	4.12	0.01	8.24	0.01							Fee Schedule		6.78							Fee Schedule																													8.24							Fee Schedule																																															
CEFZIL 250 MG/5ML SUSPENSION-50ML	250	RC	A9270	CPT				Both			129.94	58.47	0.01	116.95	0.01							Fee Schedule		96.16							Fee Schedule																													116.95							Fee Schedule																																															
CELECOXIB (CELEBREX) 100MG CAPSULE	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
CELECOXIB 200 MG CAPSULE UD	250	RC	A9270	CPT				Both			9.98	4.49	0.01	8.98	0.01							Fee Schedule		7.39							Fee Schedule																													8.98							Fee Schedule																																															
CELLACAST 3IN STCKPAD	271	RC						Both			38.85	17.48	17.48	34.97	25.25							Fee Schedule		28.75							Fee Schedule																													34.97							Fee Schedule																																															
CELLACAST 4IN STCKPAD	271	RC						Both			49.35	22.21	22.21	44.42	32.08							Fee Schedule		36.52							Fee Schedule																													44.42							Fee Schedule																																															
CELLEBRITY CYTOLOGY BRUSH #M00516151	272	RC	C1889	CPT				Both			96	43.2	43.2	86.4	62.4							Fee Schedule		71.04							Fee Schedule																													86.4							Fee Schedule																																															
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH CC					178	DRG		Inpatient			38770.12	17446.55	17446.55	17446.55							0		No services performed during 15 month lookback period. 				19504.2	19504.2	19504.2	1 through 10						7623.52	7623.52	7623.52	1 through 10						4407.32	4407.32	4407.32	1 through 10						6315.1	6315.1	6315.1	1 through 10						21937.29	21937.29	21937.29	1 through 10									0		No services provided during 15 month lookback period				4942.48	4942.48	4942.48	1 through 10									0		No services provided during 15 month lookback				6821.41	6821.41	6821.41	1 through 10									0		No services provided during 15 month lookback period	
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITHOUT CC/MCC					179	DRG		Inpatient			23318.42	10493.29	10493.29	10493.29				1219.35	1219.35	1219.35	1 through 10									0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period				3203.14	3203.14	3203.14	1 through 10						5032.18	5032.18	5032.18	1 through 10									0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period	
CEMENT BONE SIMPLEX  W/GENT. 6195-1-010	278	RC	L8699	CPT				Both			9557.1	4300.7	4300.7	8601.39		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	7072.25							Fee Schedule																													8601.39							Fee Schedule																																															
CEMENT BONE SIMPLEX HV RADIO. 6194-1-010	278	RC	L8699	CPT				Both			3609.9	1624.46	1624.46	3248.91		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	2671.33							Fee Schedule																													3248.91							Fee Schedule																																															
CEMENT BONE SIMPLEX P 6191-1-010	278	RC	L8699	CPT				Both			449.4	202.23	202.23	404.46		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	332.56							Fee Schedule																													404.46							Fee Schedule																																															
CEMENT BONE SIMPLEX W/GENT. 6195-1-001	278	RC						Both			874.13	393.36	393.36	786.72		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	646.86							Fee Schedule																													786.72							Fee Schedule																																															
CEMENT BONE SIMPLEX W/TOBRA. 6197-9-001	272	RC						Both			1309.11	589.1	589.1	1178.2	850.92							Fee Schedule		968.74							Fee Schedule																													1178.2							Fee Schedule																																															
CEMENT BONE SIMPLEX W/TOBRA. 6197-9-010	272	RC						Both			1307.25	588.26	588.26	1176.53	849.71							Fee Schedule		967.37							Fee Schedule																													1176.53							Fee Schedule																																															
CEMENT MIX (STRYKER) 0206-015	272	RC						Both			190.05	85.52	85.52	171.05	123.53							Fee Schedule		140.64							Fee Schedule																													171.05							Fee Schedule																																															
CEMENT PLUG 3	278	RC						Both			303.45	136.55	136.55	273.11		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	224.55							Fee Schedule																													273.11							Fee Schedule																																															
CEMENT SPACER	278	RC						Both			269.85	121.43	121.43	242.87		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	199.69							Fee Schedule																													242.87							Fee Schedule																																															
CENTRAL LINE DRESSING KIT DYND75222	272	RC						Both			8	3.6	3.6	7.2	5.2							Fee Schedule		5.92							Fee Schedule																													7.2							Fee Schedule																																															
CENTRAL LINE KIT SINGLE LUMEN 0600710	272	RC	A4300	CPT				Both			267.75	120.49	4.57	240.98	17.2							Fee Schedule		198.14							Fee Schedule											4.57							Fee Schedule											240.98							Fee Schedule																																															
CENTRAL VENOUS CATHETER			36571	CPT				Both			635.25	285.86	285.86	571.73	476.02							Fee Schedule		470.09							Fee Schedule																													571.73							Fee Schedule																																															
CENTRATEX CAPSULES	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
CENTROMERE AB 16088 SERUM 1ML	302	RC	86038	CPT				Both			85.05	38.27	10.74	76.55	10.74							Fee Schedule		13.43							Fee Schedule		12.45							Fee Schedule		12.09							Fee Schedule		12.09							Fee Schedule		76.55							Fee Schedule		13.9							Fee Schedule		11.24							Fee Schedule		12.09							Fee Schedule		13.9							Fee Schedule		11.24							Fee Schedule		
CEPHALEXIN 125 MG/5ML OS-100ML (KEFLEX)	250	RC	A9270	CPT				Both			74.55	33.55	0.01	67.1	0.01							Fee Schedule		55.17							Fee Schedule																													67.1							Fee Schedule																																															
CEPHALEXIN 250 MG/5ML OS-100ML (KEFLEX)	250	RC	A9270	CPT				Both			161.7	72.77	0.01	145.53	0.01							Fee Schedule		119.66							Fee Schedule																													145.53							Fee Schedule																																															
CEPHALEXIN 250MG (KEFLEX) CAPSULE	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
CEPHALEXIN 500MG (KEFLEX) CAPSULE	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
CERCLAGE WIRE 1.22MM X 30MM	272	RC						Both			88.2	39.69	39.69	79.38	57.33							Fee Schedule		65.27							Fee Schedule																													79.38							Fee Schedule																																															
CEROVITE SENIOR (CENTRUM SILVER) TABLET	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
CERULOPLASMIN QUEST 326	301	RC	82390	CPT				Both			50	22.5	9.55	45	9.55							Fee Schedule		11.93							Fee Schedule		11.06							Fee Schedule		10.74							Fee Schedule		10.74							Fee Schedule		45							Fee Schedule		12.35							Fee Schedule		9.99							Fee Schedule		10.74							Fee Schedule		12.35							Fee Schedule		9.99							Fee Schedule		
CERUMENEX DROPS	250	RC	A9270	CPT				Both			51.45	23.15	0.01	46.31	0.01							Fee Schedule		38.07							Fee Schedule																													46.31							Fee Schedule																																															
CERVARIX  (HPV) VACCINE-TYPE 16 & 18	250	RC	90650	CPT				Both			495.6	223.02	141.25	446.04	141.25							Fee Schedule		366.74							Fee Schedule																													446.04							Fee Schedule																																															
CERVICAL 1V	320	RC	72020	CPT				Both			315	141.75	11.81	318	11.81							Fee Schedule		13.83							Fee Schedule											11.95							Fee Schedule											283.5							Fee Schedule																				318							Per Diem																				
CERVICAL 2 OR 3 VIEW	320	RC	72040	CPT				Both			315	141.75	17.15	318	17.93							Fee Schedule		22.92							Fee Schedule											17.15							Fee Schedule											283.5							Fee Schedule																				318							Per Diem																				
CERVICAL 5V	320	RC	72050	CPT				Both			315	141.75	24.04	318	24.04							Fee Schedule		31.36							Fee Schedule											25.31							Fee Schedule											283.5							Fee Schedule																				318							Per Diem																				
CERVICAL 7V	320	RC	72052	CPT				Both			315	141.75	30.74	318	30.74							Fee Schedule		37.86							Fee Schedule											31.93							Fee Schedule											283.5							Fee Schedule																				318							Per Diem																				
CERVICAL COLD PACK	270	RC						Both			38.85	17.48	17.48	34.97	25.25							Fee Schedule		28.75							Fee Schedule																													34.97							Fee Schedule																																															
CERVICAL COLLAR LG #79-83017	270	RC						Both			10	4.5	4.5	9	6.5							Fee Schedule		7.4							Fee Schedule																													9							Fee Schedule																																															
CERVICAL COLLAR MED #79-83015	270	RC						Both			10	4.5	4.5	9	6.5							Fee Schedule		7.4							Fee Schedule																													9							Fee Schedule																																															
CERVICAL COLLAR SM #79-83013	270	RC						Both			10	4.5	4.5	9	6.5							Fee Schedule		7.4							Fee Schedule																													9							Fee Schedule																																															
CERVICAL COLLAR XLG	270	RC						Both			23.1	10.4	10.4	20.79	15.02							Fee Schedule		17.09							Fee Schedule																													20.79							Fee Schedule																																															
CERVICAL HOT PACK NECK CONTOUR 553795	270	RC						Both			39	17.55	17.55	35.1	25.35							Fee Schedule		28.86							Fee Schedule																													35.1							Fee Schedule																																															
CERVICAL INJECTION	370	RC	64490	CPT				Both			225.75	101.59	101.59	203.18	136.9							Fee Schedule		167.06							Fee Schedule																													203.18							Fee Schedule																																															
CERVICAL INJECTION	370	RC	64488	CPT				Both			375	168.75	93.51	337.5	93.51							Fee Schedule		277.5							Fee Schedule																													337.5							Fee Schedule																																															
CERVICAL INJECTION	370	RC	64489	CPT				Both			465	209.25	104.38	418.5	104.38							Fee Schedule		344.1							Fee Schedule																													418.5							Fee Schedule																																															
CERVICAL MYELOGRAM	320	RC	72240	CPT				Both			689.85	310.43	42.96	620.87	42.96							Fee Schedule		53.44							Fee Schedule											134.29							Fee Schedule											620.87							Fee Schedule																				318							Per Diem																				
CERVICAL PILLOW	271	RC						Both			22.05	9.92	9.92	19.85	14.33							Fee Schedule		16.32							Fee Schedule																													19.85							Fee Schedule																																															
CERVIDIL 10 MG VAGINAL INSERT	250	RC	A9270	CPT				Both			764.4	343.98	0.01	687.96	0.01							Fee Schedule		565.66							Fee Schedule																													687.96							Fee Schedule																																															
CERVIDIL 10MG INSERT	636	RC	A9270	CPT				Both			1551.9	698.36	698.36	1396.71		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1148.41							Fee Schedule																													1396.71							Fee Schedule																																															
RESPIRATORY NEOPLASMS WITH MCC					180	DRG		Inpatient			12421.08	5589.49	5589.49	5589.49							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period	
RESPIRATORY NEOPLASMS WITH CC					181	DRG		Inpatient			32633.24	14684.96	14684.96	14684.96							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period	
RESPIRATORY NEOPLASMS WITHOUT CC/MCC					182	DRG		Inpatient			21477.3	9664.79	9664.79	9664.79							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period	
MAJOR CHEST TRAUMA WITHOUT CC/MCC					185	DRG		Inpatient			25740.92	11583.41	11583.41	11583.41							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period	
PLEURAL EFFUSION WITH MCC					186	DRG		Inpatient			26656.67	11995.5	11995.5	11995.5							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback				12022.13	12022.13	12022.13	1 through 10									0		No services provided during 15 month lookback period	
CETACAINE 14% TOPICAL SPRAY-56GM	250	RC	A9270	CPT				Both			183.75	82.69	0.01	165.38	0.01							Fee Schedule		135.98							Fee Schedule																													165.38							Fee Schedule																																															
CETAPHIL LOTION- 240ML	250	RC	A9270	CPT				Both			19.95	8.98	0.01	17.96	0.01							Fee Schedule		14.76							Fee Schedule																													17.96							Fee Schedule																																															
CETIRIZINE (ZYRTEC) 5MG/5ML ORAL SOL	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
CETIRIZINE 10MG (ZyRtec) TABLET	250	RC	A9270	CPT				Both			7.35	3.31	0.01	6.62	0.01							Fee Schedule		5.44							Fee Schedule																													6.62							Fee Schedule																																															
CEVIMELINE 30 MG CAPSULE UD	250	RC	A9270	CPT				Both			8.4	3.78	0.01	7.56	0.01							Fee Schedule		6.22							Fee Schedule																													7.56							Fee Schedule																																															
CFTR  INTRON 8 POLY-T ANALYSIS 15053	301	RC	81224	CPT				Both			855	384.75	121.5	769.5	121.5							Fee Schedule		168.75							Fee Schedule		173.81							Fee Schedule		168.75							Fee Schedule		168.75							Fee Schedule		769.5							Fee Schedule		194.06							Fee Schedule		156.94							Fee Schedule											194.06							Fee Schedule		156.94							Fee Schedule		
CFVANTAGE CYSTIC FIBR EXP SCRN 92068	310	RC	81220	CPT				Both			225	101.25	101.25	640.09	400.75							Fee Schedule		556.6							Fee Schedule		573.3							Fee Schedule		556.6							Fee Schedule		556.6							Fee Schedule		202.5							Fee Schedule		640.09							Fee Schedule		517.64							Fee Schedule											640.09							Fee Schedule		517.64							Fee Schedule		
CH 50 COMPLEMENT TOTAL 618 1ML SER FZ	302	RC	86162	CPT				Both			191.1	86	18.06	171.99	18.06							Fee Schedule		22.58							Fee Schedule		20.93							Fee Schedule		20.32							Fee Schedule		20.32							Fee Schedule		171.99							Fee Schedule		23.37							Fee Schedule		18.9							Fee Schedule		20.32							Fee Schedule		23.37							Fee Schedule		18.9							Fee Schedule		
CHAGAS TRYPANOSOMA 91986 1ML SERUM REF	302	RC	86753	CPT				Both			325.5	146.48	11.01	292.95	11.01							Fee Schedule		13.76							Fee Schedule		12.76							Fee Schedule		12.39							Fee Schedule		12.39							Fee Schedule		292.95							Fee Schedule		14.25							Fee Schedule		11.52							Fee Schedule		12.39							Fee Schedule		14.25							Fee Schedule		11.52							Fee Schedule		
CHANGE-A-BLADE SCALPEL HANDLE #2200	272	RC						Both			15	6.75	6.75	13.5	9.75							Fee Schedule		11.1							Fee Schedule																													13.5							Fee Schedule																																															
CHARCOT CASTING BOOT XL #TCC21126	274	RC	L4387	CPT				Both			310	139.5	139.5	279		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	229.4							Fee Schedule		201.77							Fee Schedule											195.89							Fee Schedule		279							Fee Schedule		225.27							Fee Schedule		182.18							Fee Schedule											225.27							Fee Schedule		182.18							Fee Schedule		
CHEKMED SPOT EX GIS-44 NEW# GIS-45	272	RC						Both			119.7	53.87	53.87	107.73	77.81							Fee Schedule		88.58							Fee Schedule																													107.73							Fee Schedule																																															
CHERRY SYRUP 5ML UD	250	RC						Both			4.2	1.89	1.89	3.78	2.73							Fee Schedule		3.11							Fee Schedule																													3.78							Fee Schedule																																															
CHEST 1V	320	RC	71045	CPT				Both			315	141.75	7.8	318	8.61							Fee Schedule		14.15							Fee Schedule											7.8							Fee Schedule											283.5							Fee Schedule																				318							Per Diem																				
CHEST 4 OR MORE VIEWS	320	RC	71048	CPT				Both			630	283.5	18.86	567	20.84							Fee Schedule		24.22							Fee Schedule											18.86							Fee Schedule											567							Fee Schedule																				318							Per Diem																				
CHEST DRAIN SET PED	272	RC						Both			199.5	89.78	89.78	179.55	129.68							Fee Schedule		147.63							Fee Schedule																													179.55							Fee Schedule																																															
CHEST LORDOTIC 1V	324	RC	71045	CPT				Both			315	141.75	7.8	318	8.61							Fee Schedule		14.15							Fee Schedule											7.8							Fee Schedule											283.5							Fee Schedule																				318							Per Diem																				
CHEST PA/LAT	320	RC	71046	CPT				Both			315	141.75	14.38	318	15.89							Fee Schedule		18.7							Fee Schedule											14.38							Fee Schedule											283.5							Fee Schedule																				318							Per Diem																				
PLEURAL EFFUSION WITH CC					187	DRG		Inpatient			19959.63	8981.83	8981.83	8981.83							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period							0		No services provided during 15 month lookback period				4961.75	4961.75	4961.75	1 through 10									0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback				7519.8	7519.8	7519.8	1 through 10									0		No services provided during 15 month lookback period	
CHEST TUBE BOTTLE	272	RC						Both			199.5	89.78	89.78	179.55	129.68							Fee Schedule		147.63							Fee Schedule																													179.55							Fee Schedule																																															
CHEST TUBE DRY SUCTION A-6000-08LF	272	RC	A7048	CPT				Both			139	62.55	38.3	125.1	38.3							Fee Schedule		102.86							Fee Schedule		62.45							Fee Schedule											60.63							Fee Schedule		125.1							Fee Schedule		69.72							Fee Schedule		56.39							Fee Schedule											69.72							Fee Schedule		56.39							Fee Schedule		
CHEST TUBE TROCART	272	RC						Both			98.7	44.42	44.42	88.83	64.16							Fee Schedule		73.04							Fee Schedule																													88.83							Fee Schedule																																															
CHIBA BIO NDL 20G X 10CM	272	RC						Both			47.25	21.26	21.26	42.53	30.71							Fee Schedule		34.97							Fee Schedule																													42.53							Fee Schedule																																															
CHIBA BIO NDL 20G X 15CM	272	RC						Both			47.25	21.26	21.26	42.53	30.71							Fee Schedule		34.97							Fee Schedule																													42.53							Fee Schedule																																															
CHIBA BIO NDL 22G X 15CM	272	RC						Both			47.25	21.26	21.26	42.53	30.71							Fee Schedule		34.97							Fee Schedule																													42.53							Fee Schedule																																															
CHIBA BIOPSY NEEDLE G04338	272	RC						Both			46	20.7	20.7	41.4	29.9							Fee Schedule		34.04							Fee Schedule																													41.4							Fee Schedule																																															
CHIBA NEEDLE 18G-10 G01559	272	RC						Both			36	16.2	16.2	32.4	23.4							Fee Schedule		26.64							Fee Schedule																													32.4							Fee Schedule																																															
CHIBA NEEDLE 18G-15 G00850	272	RC						Both			36	16.2	16.2	32.4	23.4							Fee Schedule		26.64							Fee Schedule																													32.4							Fee Schedule																																															
CHIBA NEEDLE 20G-10 G01112	272	RC						Both			35	15.75	15.75	31.5	22.75							Fee Schedule		25.9							Fee Schedule																													31.5							Fee Schedule																																															
CHIBA NEEDLE 20G-15 G00777	272	RC						Both			120	54	54	108	78							Fee Schedule		88.8							Fee Schedule																													108							Fee Schedule																																															
CHIBA NEEDLE 20G-20.0 G00810	272	RC						Both			31.5	14.18	14.18	28.35	20.48							Fee Schedule		23.31							Fee Schedule																													28.35							Fee Schedule																																															
CHIBA NEEDLE 20GX20CM CHI2020   BD MEDIC	272	RC						Both			26	11.7	11.7	23.4	16.9							Fee Schedule		19.24							Fee Schedule																													23.4							Fee Schedule																																															
CHIBA NEEDLE 22-15.0 G00012	272	RC						Both			35	15.75	15.75	31.5	22.75							Fee Schedule		25.9							Fee Schedule																													31.5							Fee Schedule																																															
CHIBA NEEDLE 22G-10 G00852	272	RC						Both			35	15.75	15.75	31.5	22.75							Fee Schedule		25.9							Fee Schedule																													31.5							Fee Schedule																																															
CHIBA NEEDLE 22G-20 G00013	272	RC						Both			32.55	14.65	14.65	29.3	21.16							Fee Schedule		24.09							Fee Schedule																													29.3							Fee Schedule																																															
CHIBA NEEDLE 25G-10	272	RC						Both			47.25	21.26	21.26	42.53	30.71							Fee Schedule		34.97							Fee Schedule																													42.53							Fee Schedule																																															
CHIBA NEEDLE ECHO TIP 22G- 10	272	RC						Both			39	17.55	17.55	35.1	25.35							Fee Schedule		28.86							Fee Schedule																													35.1							Fee Schedule																																															
CHILD PERCUSSOR	271	RC						Both			7.35	3.31	3.31	6.62	4.78							Fee Schedule		5.44							Fee Schedule																													6.62							Fee Schedule																																															
CHLAMYDIA  ANTIGEN	302	RC	86631	CPT				Both			133.35	60.01	10.51	120.02	10.51							Fee Schedule		13.14							Fee Schedule		12.17							Fee Schedule		11.82							Fee Schedule		11.82							Fee Schedule		120.02							Fee Schedule		13.59							Fee Schedule		10.99							Fee Schedule		11.82							Fee Schedule		13.59							Fee Schedule		10.99							Fee Schedule		
CHLAMYDIA AB IGM 5157 SERUM	302	RC	86632	CPT				Both			106.05	47.72	11.28	95.45	11.28							Fee Schedule		14.09							Fee Schedule		13.06							Fee Schedule		12.68							Fee Schedule		12.68							Fee Schedule		95.45							Fee Schedule		14.58							Fee Schedule		11.79							Fee Schedule		12.68							Fee Schedule		14.58							Fee Schedule		11.79							Fee Schedule		
CHLAMYDIA DIRECT FLUORESCENT AB 4966)	306	RC	87270	CPT				Both			63	28.35	10.66	56.7	10.66							Fee Schedule		13.32							Fee Schedule		12.34							Fee Schedule		11.98							Fee Schedule		11.98							Fee Schedule		56.7							Fee Schedule		13.78							Fee Schedule		11.14							Fee Schedule		11.98							Fee Schedule		13.78							Fee Schedule		11.14							Fee Schedule		
CHLAMYDIA URINE 11361 URINE SP TUBE	306	RC	87591	CPT				Both			189	85.05	31.2	170.1	31.2							Fee Schedule		38.99							Fee Schedule		36.14							Fee Schedule		35.09							Fee Schedule		35.09							Fee Schedule		170.1							Fee Schedule		40.35							Fee Schedule		32.63							Fee Schedule		35.09							Fee Schedule		40.35							Fee Schedule		32.63							Fee Schedule		
CHLAMYDIA/GC 11363 SWAB	306	RC	87491	CPT				Both			189	85.05	31.2	170.1	31.2							Fee Schedule		38.99							Fee Schedule		36.14							Fee Schedule		35.09							Fee Schedule		35.09							Fee Schedule		170.1							Fee Schedule		40.35							Fee Schedule		32.63							Fee Schedule		35.09							Fee Schedule		40.35							Fee Schedule		32.63							Fee Schedule		
CHLORAL HYDRATE SYRUP 500 MG/5ML UD	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
CHLORAMPHENICOL 30541 SERUM	301	RC	82415	CPT				Both			74.55	33.55	11.26	67.1	11.26							Fee Schedule		14.08							Fee Schedule		13.05							Fee Schedule		12.67							Fee Schedule		12.67							Fee Schedule		67.1							Fee Schedule		14.57							Fee Schedule		11.78							Fee Schedule		12.67							Fee Schedule		14.57							Fee Schedule		11.78							Fee Schedule		
CHLORAPREP APPLICATOR 3ML #930415	272	RC	A4248	CPT				Both			2.9	1.31	1.25	2.61	1.25							Fee Schedule		2.15							Fee Schedule																													2.61							Fee Schedule																																															
CHLORAPREP SWABSTICKS 260103	272	RC						Both			2.7	1.22	1.22	2.43	1.76							Fee Schedule		2							Fee Schedule																													2.43							Fee Schedule																																															
CHLORAPREP W/TINT 26ML #67130 ( SENECA	272	RC						Both			18.65	8.39	8.39	16.79	12.12							Fee Schedule		13.8							Fee Schedule																													16.79							Fee Schedule																																															
CHLORASEPTIC 1.4% SPRAY - 20ML	250	RC	A9270	CPT				Both			8.97	4.04	0.01	8.07	0.01							Fee Schedule		6.64							Fee Schedule																													8.07							Fee Schedule																																															
CHLORASEPTIC LOZENGE	250	RC	A9270	CPT				Both			2.63	1.18	0.01	2.37	0.01							Fee Schedule		1.95							Fee Schedule																													2.37							Fee Schedule																																															
CHLORDIAZ/CLIND  (LIBRAX)   5-2.5 MG CAP	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
CHLORDIAZEPOXIDE  10 MG CAPSULE UD	250	RC	A9270	CPT				Both			4.2	1.89	0.01	3.78	0.01							Fee Schedule		3.11							Fee Schedule																													3.78							Fee Schedule																																															
CHLORDIAZEPOXIDE  5 MG CAPSULE	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
CHLORDIAZEPOXIDE 10MG CAPSULE	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
CHLORDIAZEPOXIDE 25 MG CAPSULE	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
CHLORDIAZEPOXIDE 5MG CAPSULE	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
CHLORHEXADINE CLOTH BATH SAGE 9707	270	RC						Both			17.85	8.03	8.03	16.07	11.6							Fee Schedule		13.21							Fee Schedule																													16.07							Fee Schedule																																															
CHLORHEXIDINE GLUCONATE ORAL RINSE 0.12%	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
CHLORIDE	301	RC	82435	CPT				Both			52.5	23.63	4.09	47.25	4.09							Fee Schedule		5.11							Fee Schedule		4.74							Fee Schedule		4.6							Fee Schedule		4.6							Fee Schedule		47.25							Fee Schedule		5.29							Fee Schedule		4.28							Fee Schedule		4.6							Fee Schedule		5.29							Fee Schedule		4.28							Fee Schedule		
CHLORIDE CSF	301	RC	82438	CPT				Both			25.2	11.34	4.34	22.68	4.34							Fee Schedule		5.43							Fee Schedule		5.15							Fee Schedule		5							Fee Schedule		5							Fee Schedule		22.68							Fee Schedule		5.75							Fee Schedule		4.65							Fee Schedule		5							Fee Schedule		5.75							Fee Schedule		4.65							Fee Schedule		
CHLORIDE URINE 24 HR 11314 REF LAB	301	RC	82436	CPT				Both			56.7	25.52	4.47	51.03	4.47							Fee Schedule		5.75							Fee Schedule		5.92							Fee Schedule		5.75							Fee Schedule		5.75							Fee Schedule		51.03							Fee Schedule		6.61							Fee Schedule		5.35							Fee Schedule		5.75							Fee Schedule		6.61							Fee Schedule		5.35							Fee Schedule		
CHLORIDE URINE RANDOM	301	RC	82436	CPT				Both			26.25	11.81	4.47	23.63	4.47							Fee Schedule		5.75							Fee Schedule		5.92							Fee Schedule		5.75							Fee Schedule		5.75							Fee Schedule		23.63							Fee Schedule		6.61							Fee Schedule		5.35							Fee Schedule		5.75							Fee Schedule		6.61							Fee Schedule		5.35							Fee Schedule		
ChlorPROMazine 10 MG TABLET UD	250	RC	A9270	CPT				Both			5.25	2.36	0.01	4.73	0.01							Fee Schedule		3.89							Fee Schedule																													4.73							Fee Schedule																																															
ChlorPROMazine 25 MG/ML (THORAZINE) AMP	636	RC	J3230	CPT				Both			26.25	11.81	2.7	23.63		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	19.43							Fee Schedule		18.69							Fee Schedule		2.7							Fee Schedule		18.14							Fee Schedule		23.63							Fee Schedule		20.86							Fee Schedule		16.87							Fee Schedule											20.86							Fee Schedule		16.87							Fee Schedule		
chlorPROMAzine 25MG (THORAZINE) TABLET	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
ChlorPROPamide 100 MG TABLET UD	250	RC	A9270	CPT				Both			4.2	1.89	0.01	3.78	0.01							Fee Schedule		3.11							Fee Schedule																													3.78							Fee Schedule																																															
ChlorPROPAMIDE 250 MG TABLET UD	250	RC	A9270	CPT				Both			4.2	1.89	0.01	3.78	0.01							Fee Schedule		3.11							Fee Schedule																													3.78							Fee Schedule																																															
chlorTHALIdone 25MG TABLET	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
CHO PAT KNEE	274	RC	L1832	CPT				Both			68.25	30.71	30.71	1071.24		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	50.51							Fee Schedule		959.46							Fee Schedule		580.58							Fee Schedule		931.51							Fee Schedule		61.43							Fee Schedule		1071.24							Fee Schedule		866.3							Fee Schedule											1071.24							Fee Schedule		866.3							Fee Schedule		
CHOLANGIO CATH EBC04	272	RC						Both			308.7	138.92	138.92	277.83	200.66							Fee Schedule		228.44							Fee Schedule																													277.83							Fee Schedule																																															
CHOLANGIOCATH 4 FR. #420404F (Edwards li	272	RC						Both			141.75	63.79	63.79	127.58	92.14							Fee Schedule		104.9							Fee Schedule																													127.58							Fee Schedule																																															
CHOLANGIOCATH ORIGIN	272	RC						Both			135.45	60.95	60.95	121.91	88.04							Fee Schedule		100.23							Fee Schedule																													121.91							Fee Schedule																																															
CHOLANGIOCATH SET #CS-01700	272	RC						Both			253	113.85	113.85	227.7	164.45							Fee Schedule		187.22							Fee Schedule																													227.7							Fee Schedule																																															
CHOLANGIOCATH TAUT 20018-M56	271	RC						Both			149	67.05	67.05	134.1	96.85							Fee Schedule		110.26							Fee Schedule																													134.1							Fee Schedule																																															
PULMONARY EDEMA AND RESPIRATORY FAILURE					189	DRG		Inpatient			34073.43	15333.04	15333.04	15333.04							0		No services performed during 15 month lookback period. 				4164.57	553.08	7161.55	1 through 10						11409.17	1140.92	10268.65	1 through 10						4921.82	4921.82	4921.82	1 through 10						6769.85	3705.33	9851.6	23									0		No services provided during 15 month lookback period				9661.43	9661.43	9661.43	1 through 10						4502.23	4502.23	4502.23	12									0		No services provided during 15 month lookback				9360.17	9360.17	9360.17	1 through 10						3731.79	3731.79	3731.79	1 through 10			
CHOLESTEROL	301	RC	82465	CPT				Both			90.3	40.64	3.87	81.27	3.87							Fee Schedule		4.84							Fee Schedule		4.48							Fee Schedule		4.35							Fee Schedule		4.35							Fee Schedule		81.27							Fee Schedule		5							Fee Schedule		4.05							Fee Schedule		4.35							Fee Schedule		5							Fee Schedule		4.05							Fee Schedule		
CHOLESTEROL BODY FLUID 1652 1ML BODY FL	301	RC	84311	CPT				Both			52.5	23.63	6.21	47.25	6.21							Fee Schedule		8.1							Fee Schedule		8.34							Fee Schedule		8.1							Fee Schedule		8.1							Fee Schedule		47.25							Fee Schedule		9.32							Fee Schedule		7.53							Fee Schedule		8.1							Fee Schedule		9.32							Fee Schedule		7.53							Fee Schedule		
"CHOLESTEROL, PLEURAL FLD 17586"	301	RC	84311	CPT				Both			13.5	6.08	6.08	12.15	6.21							Fee Schedule		8.1							Fee Schedule		8.34							Fee Schedule		8.1							Fee Schedule		8.1							Fee Schedule		12.15							Fee Schedule		9.32							Fee Schedule		7.53							Fee Schedule		8.1							Fee Schedule		9.32							Fee Schedule		7.53							Fee Schedule		
CHOLESTYRAMINE 4GM PACKET	250	RC	A9270	CPT				Both			8.4	3.78	0.01	7.56	0.01							Fee Schedule		6.22							Fee Schedule																													7.56							Fee Schedule																																															
CHOLINESTERASE 37965 SERUM	301	RC	82480	CPT				Both			52.5	23.63	7	47.25	7							Fee Schedule		8.75							Fee Schedule		8.11							Fee Schedule		7.87							Fee Schedule		7.87							Fee Schedule		47.25							Fee Schedule		9.05							Fee Schedule		7.32							Fee Schedule		7.87							Fee Schedule		9.05							Fee Schedule		7.32							Fee Schedule		
CHOLINESTERASE ACETYL 337  2 LAV TUBES	301	RC	82013	CPT				Both			142.8	64.26	9.93	128.52	9.93							Fee Schedule		12.41							Fee Schedule		12.66							Fee Schedule		12.29							Fee Schedule		12.29							Fee Schedule		128.52							Fee Schedule		14.13							Fee Schedule		11.43							Fee Schedule		12.29							Fee Schedule		14.13							Fee Schedule		11.43							Fee Schedule		
CHOLINESTERASE RBC 335 2 LAV TUBES	301	RC	82482	CPT				Both			52.5	23.63	7.06	47.25	7.06							Fee Schedule		9.81							Fee Schedule		10.1							Fee Schedule		9.81							Fee Schedule		9.81							Fee Schedule		47.25							Fee Schedule		11.28							Fee Schedule		9.12							Fee Schedule		9.81							Fee Schedule		11.28							Fee Schedule		9.12							Fee Schedule		
CHROM CV CUTT 2.0 M759G	272	RC						Both			68.25	30.71	30.71	61.43	44.36							Fee Schedule		50.51							Fee Schedule																													61.43							Fee Schedule																																															
CHROM MULTIPK1 3 803	272	RC						Both			18.9	8.51	8.51	17.01	12.29							Fee Schedule		13.99							Fee Schedule																													17.01							Fee Schedule																																															
CHROMATIN (NUCLEOSOMAL) AB 34088 1ML SER	300	RC	86235	CPT				Both			131.25	59.06	15.94	118.13	15.94							Fee Schedule		19.93							Fee Schedule		18.47							Fee Schedule		17.93							Fee Schedule		17.93							Fee Schedule		118.13							Fee Schedule		20.62							Fee Schedule		16.67							Fee Schedule		17.93							Fee Schedule		20.62							Fee Schedule		16.67							Fee Schedule		
CHROME GI 4 0 G121H	272	RC						Both			8.4	3.78	3.78	7.56	5.46							Fee Schedule		6.22							Fee Schedule																													7.56							Fee Schedule																																															
CHROMIC 0  47T	272	RC						Both			35	15.75	15.75	31.5	22.75							Fee Schedule		25.9							Fee Schedule																													31.5							Fee Schedule																																															
CHROMIC 0 802H	272	RC						Both			7.35	3.31	3.31	6.62	4.78							Fee Schedule		5.44							Fee Schedule																													6.62							Fee Schedule																																															
CHROMIC 0 817H	272	RC						Both			10.5	4.73	4.73	9.45	6.83							Fee Schedule		7.77							Fee Schedule																													9.45							Fee Schedule																																															
CHROMIC 0 904H	272	RC						Both			11	4.95	4.95	9.9	7.15							Fee Schedule		8.14							Fee Schedule																													9.9							Fee Schedule																																															
CHROMIC 0 944	272	RC						Both			23.1	10.4	10.4	20.79	15.02							Fee Schedule		17.09							Fee Schedule																													20.79							Fee Schedule																																															
CHROMIC 0 L114G	272	RC						Both			13	5.85	5.85	11.7	8.45							Fee Schedule		9.62							Fee Schedule																													11.7							Fee Schedule																																															
CHROMIC 0 SG-14T	272	RC						Both			29.4	13.23	13.23	26.46	19.11							Fee Schedule		21.76							Fee Schedule																													26.46							Fee Schedule																																															
CHROMIC 0 U256H	272	RC						Both			13	5.85	5.85	11.7	8.45							Fee Schedule		9.62							Fee Schedule																													11.7							Fee Schedule																																															
CHROMIC 1 #925H	272	RC						Both			11	4.95	4.95	9.9	7.15							Fee Schedule		8.14							Fee Schedule																													9.9							Fee Schedule																																															
CHROMIC 1 #925H	272	RC						Both			11	4.95	4.95	9.9	7.15							Fee Schedule		8.14							Fee Schedule																													9.9							Fee Schedule																																															
CHROMIC 1 813H	272	RC						Both			11	4.95	4.95	9.9	7.15							Fee Schedule		8.14							Fee Schedule																													9.9							Fee Schedule																																															
CHROMIC 1 945H	272	RC						Both			17	7.65	7.65	15.3	11.05							Fee Schedule		12.58							Fee Schedule																													15.3							Fee Schedule																																															
CHROMIC 1.0 U247H	272	RC						Both			10.5	4.73	4.73	9.45	6.83							Fee Schedule		7.77							Fee Schedule																													9.45							Fee Schedule																																															
CHROMIC 2.0 816H	272	RC						Both			10.5	4.73	4.73	9.45	6.83							Fee Schedule		7.77							Fee Schedule																													9.45							Fee Schedule																																															
CHROMIC 2.0 G-153-H	272	RC						Both			22.05	9.92	9.92	19.85	14.33							Fee Schedule		16.32							Fee Schedule																													19.85							Fee Schedule																																															
CHROMIC 2.0 GL31G	272	RC						Both			23	10.35	10.35	20.7	14.95							Fee Schedule		17.02							Fee Schedule																													20.7							Fee Schedule																																															
CHROMIC 2.0 U255H	272	RC						Both			14	6.3	6.3	12.6	9.1							Fee Schedule		10.36							Fee Schedule																													12.6							Fee Schedule																																															
CHROMIC 2-0 811H	272	RC						Both			10	4.5	4.5	9	6.5							Fee Schedule		7.4							Fee Schedule																													9							Fee Schedule																																															
CHROMIC 2-0 923H	272	RC						Both			11	4.95	4.95	9.9	7.15							Fee Schedule		8.14							Fee Schedule																													9.9							Fee Schedule																																															
CHROMIC 2-0 G123H	272	RC						Both			10	4.5	4.5	9	6.5							Fee Schedule		7.4							Fee Schedule																													9							Fee Schedule																																															
CHROMIC 2-0 G123H	272	RC						Both			10	4.5	4.5	9	6.5							Fee Schedule		7.4							Fee Schedule																													9							Fee Schedule																																															
CHROMIC 2-0 GL31G	272	RC						Both			28	12.6	12.6	25.2	18.2							Fee Schedule		20.72							Fee Schedule																													25.2							Fee Schedule																																															
CHROMIC 2-0 J905T	272	RC						Both			23.1	10.4	10.4	20.79	15.02							Fee Schedule		17.09							Fee Schedule																													20.79							Fee Schedule																																															
CHROMIC 2-0 L113G	272	RC						Both			14	6.3	6.3	12.6	9.1							Fee Schedule		10.36							Fee Schedule																													12.6							Fee Schedule																																															
CHROMIC 3.0 810H	272	RC						Both			11.55	5.2	5.2	10.4	7.51							Fee Schedule		8.55							Fee Schedule																													10.4							Fee Schedule																																															
CHROMIC 3.0 832H	272	RC						Both			13.65	6.14	6.14	12.29	8.87							Fee Schedule		10.1							Fee Schedule																													12.29							Fee Schedule																																															
CHROMIC 3.0 932H	272	RC						Both			12.6	5.67	5.67	11.34	8.19							Fee Schedule		9.32							Fee Schedule																													11.34							Fee Schedule																																															
CHROMIC 3-0 (663H  DISC) 1663H	272	RC						Both			14	6.3	6.3	12.6	9.1							Fee Schedule		10.36							Fee Schedule																													12.6							Fee Schedule																																															
CHROMIC 3-0 1893G	272	RC						Both			23.1	10.4	10.4	20.79	15.02							Fee Schedule		17.09							Fee Schedule																													20.79							Fee Schedule																																															
CHROMIC 3-0 432H	272	RC						Both			11.55	5.2	5.2	10.4	7.51							Fee Schedule		8.55							Fee Schedule																													10.4							Fee Schedule																																															
CHROMIC 3-0 636H *DISC*	272	RC						Both			10	4.5	4.5	9	6.5							Fee Schedule		7.4							Fee Schedule																													9							Fee Schedule																																															
CHROMIC 3-0 922H	272	RC						Both			13	5.85	5.85	11.7	8.45							Fee Schedule		9.62							Fee Schedule																													11.7							Fee Schedule																																															
CHROMIC 3-0 G122H	272	RC						Both			11	4.95	4.95	9.9	7.15							Fee Schedule		8.14							Fee Schedule																													9.9							Fee Schedule																																															
CHROMIC 3-0 GI G122H	272	RC						Both			10	4.5	4.5	9	6.5							Fee Schedule		7.4							Fee Schedule																													9							Fee Schedule																																															
CHROMIC 3-0 J904T	272	RC						Both			23.1	10.4	10.4	20.79	15.02							Fee Schedule		17.09							Fee Schedule																													20.79							Fee Schedule																																															
CHROMIC 4.0 635H *DISC*	272	RC						Both			7.35	3.31	3.31	6.62	4.78							Fee Schedule		5.44							Fee Schedule																													6.62							Fee Schedule																																															
CHROMIC 4.0 793G	272	RC						Both			60	27	27	54	39							Fee Schedule		44.4							Fee Schedule																													54							Fee Schedule																																															
CHROMIC 4.0 793G	272	RC						Both			43.05	19.37	19.37	38.75	27.98							Fee Schedule		31.86							Fee Schedule																													38.75							Fee Schedule																																															
CHROMIC 4.0 U203H	272	RC						Both			10	4.5	4.5	9	6.5							Fee Schedule		7.4							Fee Schedule																													9							Fee Schedule																																															
CHROMIC 4-0  VCP507G (1643G DISC)	272	RC						Both			15	6.75	6.75	13.5	9.75							Fee Schedule		11.1							Fee Schedule																													13.5							Fee Schedule																																															
CHROMIC 48G	272	RC						Both			40.95	18.43	18.43	36.86	26.62							Fee Schedule		30.3							Fee Schedule																													36.86							Fee Schedule																																															
CHROMIC 5.0 G120	272	RC						Both			23.1	10.4	10.4	20.79	15.02							Fee Schedule		17.09							Fee Schedule																													20.79							Fee Schedule																																															
CHROMIC REEL O L114	272	RC						Both			11.55	5.2	5.2	10.4	7.51							Fee Schedule		8.55							Fee Schedule																													10.4							Fee Schedule																																															
CHROMIUM 5248 ROYAL BLUE TUBE	301	RC	82495	CPT				Both			158.55	71.35	18.03	142.7	18.03							Fee Schedule		22.53							Fee Schedule		20.89							Fee Schedule		20.28							Fee Schedule		20.28							Fee Schedule		142.7							Fee Schedule		23.32							Fee Schedule		18.86							Fee Schedule		20.28							Fee Schedule		23.32							Fee Schedule		18.86							Fee Schedule		
CHROMIUM PLASMA 3484	301	RC	82495	CPT				Both			165	74.25	18.03	148.5	18.03							Fee Schedule		22.53							Fee Schedule		20.89							Fee Schedule		20.28							Fee Schedule		20.28							Fee Schedule		148.5							Fee Schedule		23.32							Fee Schedule		18.86							Fee Schedule		20.28							Fee Schedule		23.32							Fee Schedule		18.86							Fee Schedule		
CHROMOGRANIN A 31911 PLAIN RED	300	RC	86316	CPT				Both			248.85	111.98	18.5	223.97	18.5							Fee Schedule		23.13							Fee Schedule		21.43							Fee Schedule		20.81							Fee Schedule		20.81							Fee Schedule		223.97							Fee Schedule		23.93							Fee Schedule		19.35							Fee Schedule		20.81							Fee Schedule		23.93							Fee Schedule		19.35							Fee Schedule		
CHROMOSOME ANAL AMNIOTIC FLUID 14590	311	RC	88269	CPT				Both			897.75	403.99	147.84	807.98	147.84							Fee Schedule		184.81							Fee Schedule		178.87							Fee Schedule		173.66							Fee Schedule		173.66							Fee Schedule		807.98							Fee Schedule		199.71							Fee Schedule		161.5							Fee Schedule											199.71							Fee Schedule		161.5							Fee Schedule		
CHROMOSOME ANAL FRAGILE X 16313 EDTA	301	RC	81243	CPT				Both			519.75	233.89	41.07	467.78	41.07							Fee Schedule		57.04							Fee Schedule		58.75							Fee Schedule		57.04							Fee Schedule		57.04							Fee Schedule		467.78							Fee Schedule		65.6							Fee Schedule		53.05							Fee Schedule		57.04							Fee Schedule		65.6							Fee Schedule		53.05							Fee Schedule		
CHROMOSOME ANAL PERIPH 14596	310	RC	88262	CPT				Both			1096.2	493.29	110.79	986.58	110.79							Fee Schedule		138.49							Fee Schedule		129.25							Fee Schedule		125.49							Fee Schedule		125.49							Fee Schedule		986.58							Fee Schedule		144.31							Fee Schedule		116.71							Fee Schedule											144.31							Fee Schedule		116.71							Fee Schedule		
CHROMOSOME ANALYSIS FOR GENETIC DEFECTS	310	RC	88262	CPT				Both			1096.2	493.29	110.79	986.58	110.79							Fee Schedule		138.49							Fee Schedule		129.25							Fee Schedule		125.49							Fee Schedule		125.49							Fee Schedule		986.58							Fee Schedule		144.31							Fee Schedule		116.71							Fee Schedule											144.31							Fee Schedule		116.71							Fee Schedule		
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH MCC					190	DRG		Inpatient			47441.17	21348.53	21348.53	21348.53							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period. 				1198.78	1198.78	1198.78	1 through 10									0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period				5567.62	5567.62	5567.62	1 through 10									0		No services provided during 15 month lookback							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period	
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH CC					191	DRG		Inpatient			26565.48	11954.47	11954.47	11954.47				9602.2	9602.2	9602.2	1 through 10						4916.75	4916.75	4916.75	1 through 10									0		No services performed during 15 month lookback period				3294.66	3294.66	3294.66	1 through 10						4397.79	4397.79	4397.79	1 through 10									0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period				3376.95	3376.95	3376.95	1 through 10									0		No services provided during 15 month lookback				6956.42	6956.42	6956.42	1 through 10						778.84	778.84	778.84	1 through 10			
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITHOUT CC/MCC					192	DRG		Inpatient			22932.32	10319.54	10319.54	10319.54							0		No services performed during 15 month lookback period. 				4262.89	969.58	9905.81	1 through 10									0		No services performed during 15 month lookback period				2267.76	2267.76	2267.76	1 through 10									0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback				6658.39	6658.39	6658.39	1 through 10									0		No services provided during 15 month lookback period	
CHRONIC URTICARIA  PANEL 16440 5ML SERUM	302	RC	86343	CPT				Both			184.8	83.16	11.07	166.32	11.07							Fee Schedule		13.84							Fee Schedule		12.83							Fee Schedule		12.46							Fee Schedule		12.46							Fee Schedule		166.32							Fee Schedule		14.33							Fee Schedule		11.59							Fee Schedule		12.46							Fee Schedule		14.33							Fee Schedule		11.59							Fee Schedule		
CILOSTAZOL 100MG (PLETAL) TABLET	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
CIMETIDINE 150 MG/ML INJECTION-2ML VIAL	250	RC	S0023	CPT				Both			11.55	5.2	2.38	10.4	2.38							Fee Schedule		8.55							Fee Schedule																													10.4							Fee Schedule																																															
CIMETIDINE 300 MG TABLET UD	250	RC	A9270	CPT				Both			4.2	1.89	0.01	3.78	0.01							Fee Schedule		3.11							Fee Schedule																													3.78							Fee Schedule																																															
CIMETIDINE 300 MG/5ML LIQUID UD	250	RC	A9270	CPT				Both			6.04	2.72	0.01	5.44	0.01							Fee Schedule		4.47							Fee Schedule																													5.44							Fee Schedule																																															
CIMETIDINE 400 MG TABLET UD	250	RC	A9270	CPT				Both			5.25	2.36	0.01	4.73	0.01							Fee Schedule		3.89							Fee Schedule																													4.73							Fee Schedule																																															
CIPRO HC 0.2-1% OTIC SUSP- 10ML	250	RC	A9270	CPT				Both			1193.98	537.29	0.01	1074.58	0.01							Fee Schedule		883.55							Fee Schedule																													1074.58							Fee Schedule																																															
CIPRODEX OTIC SUSPENSION	250	RC	J7342	CPT				Both			728.7	327.92	28.2	655.83	28.2							Fee Schedule		539.24							Fee Schedule																													655.83							Fee Schedule																																															
CIPROFLOXACIN 0.3% OPTH SOL.	250	RC	A9270	CPT				Both			78.75	35.44	0.01	70.88	0.01							Fee Schedule		58.28							Fee Schedule																													70.88							Fee Schedule																																															
CIPROFLOXACIN 10 MG/ML INJECTION-40ML VL	636	RC	J0744	CPT				Both			47.25	21.26	1.6	42.53		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	34.97							Fee Schedule		1.77							Fee Schedule											1.72							Fee Schedule		42.53							Fee Schedule		1.98							Fee Schedule		1.6							Fee Schedule											1.98							Fee Schedule		1.6							Fee Schedule		
CIPROFLOXACIN 200MG/100 ML(CIPRO) PREMIX	636	RC	J0744	CPT				Both			49.35	22.21	1.6	44.42		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	36.52							Fee Schedule		1.77							Fee Schedule											1.72							Fee Schedule		44.42							Fee Schedule		1.98							Fee Schedule		1.6							Fee Schedule											1.98							Fee Schedule		1.6							Fee Schedule		
CIPROFLOXACIN 400MG/200ML (CIPRO) PREMIX	636	RC	J0744	CPT				Both			98.7	44.42	1.6	88.83		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	73.04							Fee Schedule		1.77							Fee Schedule											1.72							Fee Schedule		88.83							Fee Schedule		1.98							Fee Schedule		1.6							Fee Schedule											1.98							Fee Schedule		1.6							Fee Schedule		
CIPROFLOXACIN 500MG (CIPRO) TABLET	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
CIRCON DISPOSA. TOP	272	RC						Both			15.75	7.09	7.09	14.18	10.24							Fee Schedule		11.66							Fee Schedule																													14.18							Fee Schedule																																															
CIRCON GRASPING FORCEPS	272	RC						Both			539.7	242.87	242.87	485.73	350.81							Fee Schedule		399.38							Fee Schedule																													485.73							Fee Schedule																																															
CIRCON HELICAL BASKET	272	RC						Both			405.3	182.39	182.39	364.77	263.45							Fee Schedule		299.92							Fee Schedule																													364.77							Fee Schedule																																															
CIRCUIT FOR PARAPAC PORT. VENT.	272	RC						Both			61	27.45	27.45	54.9	39.65							Fee Schedule		45.14							Fee Schedule																													54.9							Fee Schedule																																															
CIRCUMCISION DRAPE 19 X12  DYNJP6003	272	RC						Both			6	2.7	2.7	5.4	3.9							Fee Schedule		4.44							Fee Schedule																													5.4							Fee Schedule																																															
CIRCUMCISION STRAP 31309480	270	RC						Both			1.1	0.5	0.5	0.99	0.72							Fee Schedule		0.81							Fee Schedule																													0.99							Fee Schedule																																															
CIRCUMCISION TRAY DYNJ04078	272	RC	A4550	CPT				Both			22	9.9	9.9	36.53	15.31							Fee Schedule		16.28							Fee Schedule											36.53							Fee Schedule											19.8							Fee Schedule																																															
SIMPLE PNEUMONIA AND PLEURISY WITH MCC					193	DRG		Inpatient			35534.81	15990.66	15990.66	15990.66							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period. 				10135.54	1013.55	9121.98	1 through 10									0		No services provided during 15 month lookback period				5669.61	5669.61	5669.61	1 through 10									0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period				5278.48	5278.48	5278.48	1 through 10									0		No services provided during 15 month lookback				9760.85	9760.85	9760.85	1 through 10									0		No services provided during 15 month lookback period	
SIMPLE PNEUMONIA AND PLEURISY WITH CC					194	DRG		Inpatient			27054.63	12174.58	12174.58	12174.58							0		No services performed during 15 month lookback period. 				5601.07	579.28	13568.2	1 through 10						417.13	417.13	417.13	1 through 10						3338.45	3338.45	3338.45	1 through 10						4736.45	3766.18	7214.65	23									0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period				3329.99	3329.99	3329.99	1 through 10									0		No services provided during 15 month lookback				6745.32	6745.32	6745.32	1 through 10						2018.88	2018.88	2018.88	1 through 10			
SIMPLE PNEUMONIA AND PLEURISY WITHOUT CC/MCC					195	DRG		Inpatient			24507.73	11028.48	11028.48	11028.48							0		No services performed during 15 month lookback period. 				3339.36	2130.75	6638.95	1 through 10						5785.61	5785.61	5785.61	1 through 10						1883.03	1883.03	1883.03	1 through 10						3750.11	3750.11	3750.11	1 through 10						13769.8	13769.8	13769.8	1 through 10									0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback							0		No services provided during 15 month lookback period				2634.98	2634.98	2634.98	1 through 10			
CISATRACURIUM 2 MG/ML INJECTION	250	RC						Both			69.3	31.19	31.19	62.37	45.05							Fee Schedule		51.28							Fee Schedule																													62.37							Fee Schedule																																															
CITALOPRAM 10MG (CELEXA) TABLET	250	RC	A9270	CPT				Both			7.35	3.31	0.01	6.62	0.01							Fee Schedule		5.44							Fee Schedule																													6.62							Fee Schedule																																															
CITALOPRAM 20MG (CELEXA) TABLET	250	RC	A9270	CPT				Both			9.45	4.25	0.01	8.51	0.01							Fee Schedule		6.99							Fee Schedule																													8.51							Fee Schedule																																															
CITRIC ACID 4616 URINE	301	RC	82507	CPT				Both			256.2	115.29	24.72	230.58	24.72							Fee Schedule		30.89							Fee Schedule		28.63							Fee Schedule		27.8							Fee Schedule		27.8							Fee Schedule		230.58							Fee Schedule		31.97							Fee Schedule		25.85							Fee Schedule		27.8							Fee Schedule		31.97							Fee Schedule		25.85							Fee Schedule		
CITRUCEL PACKET UD	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
CIVCO PROBE COVER 610-575	272	RC						Both			16.5	7.43	7.43	14.85	10.73							Fee Schedule		12.21							Fee Schedule																													14.85							Fee Schedule																																															
CLAMP ADJUSTABLE WIRE/PIN	278	RC	C1713	CPT				Both			3382.05	1521.92	1521.92	3043.85		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	2502.72							Fee Schedule																													3043.85							Fee Schedule																																															
CLAMP COMP.	278	RC						Both			1180.2	531.09	531.09	1062.18		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	873.35							Fee Schedule																													1062.18							Fee Schedule																																															
CLAMP RING TO ROD	278	RC	C1713	CPT				Both			3787.35	1704.31	1704.31	3408.62		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	2802.64							Fee Schedule																													3408.62							Fee Schedule																																															
CLARINEX 5 MG TABLET U/D	250	RC	A9270	CPT				Both			7.88	3.55	0.01	7.09	0.01							Fee Schedule		5.83							Fee Schedule																													7.09							Fee Schedule																																															
CLARITHROMYCIN 500MG (BIAXIN) TABLET	250	RC	A9270	CPT				Both			16.8	7.56	0.01	15.12	0.01							Fee Schedule		12.43							Fee Schedule																													15.12							Fee Schedule																																															
CLARITIN-D 12 HR TABLET UD	250	RC	A9270	CPT				Both			4.2	1.89	0.01	3.78	0.01							Fee Schedule		3.11							Fee Schedule																													3.78							Fee Schedule																																															
CLAVICLE BRACE INF	274	RC	L3650	CPT				Both			57.75	25.99	25.99	77.41		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	42.74							Fee Schedule		69.33							Fee Schedule		52.13							Fee Schedule		67.31							Fee Schedule		51.98							Fee Schedule		77.41							Fee Schedule		62.6							Fee Schedule											77.41							Fee Schedule		62.6							Fee Schedule		
CLAVICLE BRACE LG #79-85007	274	RC						Both			12	5.4	5.4	10.8		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	8.88							Fee Schedule																													10.8							Fee Schedule																																															
CLAVICLE BRACE MED #79-85005	274	RC						Both			12	5.4	5.4	10.8		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	8.88							Fee Schedule																													10.8							Fee Schedule																																															
CLAVICLE BRACE SM #79-85003	274	RC	L3650	CPT				Both			12	5.4	5.4	77.41		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	8.88							Fee Schedule		69.33							Fee Schedule		52.13							Fee Schedule		67.31							Fee Schedule		10.8							Fee Schedule		77.41							Fee Schedule		62.6							Fee Schedule											77.41							Fee Schedule		62.6							Fee Schedule		
CLAVICLE BRACE XL #79-85008	274	RC	L3650	CPT				Both			18.9	8.51	8.51	77.41		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	13.99							Fee Schedule		69.33							Fee Schedule		52.13							Fee Schedule		67.31							Fee Schedule		17.01							Fee Schedule		77.41							Fee Schedule		62.6							Fee Schedule											77.41							Fee Schedule		62.6							Fee Schedule		
CLAVICLE LT	320	RC	73000	CPT				Both			315	141.75	15.04	318	15.89							Fee Schedule		18.7							Fee Schedule											15.04							Fee Schedule											283.5							Fee Schedule																				318							Per Diem																				
CLAVICLE RT	320	RC	73000	CPT				Both			315	141.75	15.04	318	15.89							Fee Schedule		18.7							Fee Schedule											15.04							Fee Schedule											283.5							Fee Schedule																				318							Per Diem																				
CLEAN CATCH	272	RC						Both			4.2	1.89	1.89	3.78	2.73							Fee Schedule		3.11							Fee Schedule																													3.78							Fee Schedule																																															
CLEAR INTERJECT NEEDLE #M00518301	272	RC						Both			95	42.75	42.75	85.5	61.75							Fee Schedule		70.3							Fee Schedule																													85.5							Fee Schedule																																															
CLEAR LIGATOR KIT 5 BAND 000221 (CONMED)	272	RC						Both			236.25	106.31	106.31	212.63	153.56							Fee Schedule		174.83							Fee Schedule																													212.63							Fee Schedule																																															
CLEAR STAXX FINGER SPLINT	270	RC						Both			4.2	1.89	1.89	3.78	2.73							Fee Schedule		3.11							Fee Schedule																													3.78							Fee Schedule																																															
CLEARIFY VISUALIZATION SYSTEM #LAPVUE10	272	RC						Both			90	40.5	40.5	81	58.5							Fee Schedule		66.6							Fee Schedule																													81							Fee Schedule																																															
CLENPIQ BOWEL PREP	250	RC	A9270	CPT				Both			630.54	283.74	0.01	567.49	0.01							Fee Schedule		466.6							Fee Schedule																													567.49							Fee Schedule																																															
CLEOCIN  75 MG/5ML SUSP-100ML	250	RC	A9270	CPT				Both			86.89	39.1	0.01	78.2	0.01							Fee Schedule		64.3							Fee Schedule																													78.2							Fee Schedule																																															
CLEOCIN 100 MG OVULE SUPP	250	RC	A9270	CPT				Both			189	85.05	0.01	170.1	0.01							Fee Schedule		139.86							Fee Schedule																													170.1							Fee Schedule																																															
CLIN PATHOLOGY CONSULT COMPREHENSIVE	310	RC	80502	CPT				Both			165.9	74.66	49.91	149.31	49.91							Fee Schedule		122.77							Fee Schedule																													149.31							Fee Schedule																																															
CLIN PATHOLOGY CONSULT LIMITED	310	RC	80500	CPT				Both			165.9	74.66	13.83	149.31	13.83							Fee Schedule		122.77							Fee Schedule																													149.31							Fee Schedule																																															
CLINDAMYCIN  150MG (CLEOCIN) CAPSULE	250	RC	A9270	CPT				Both			5.25	2.36	0.01	4.73	0.01							Fee Schedule		3.89							Fee Schedule																													4.73							Fee Schedule																																															
CLINDAMYCIN  300 MG (CLEOCIN) PREMIX	250	RC	J0736	CPT				Both			27.3	12.29	1.84	24.57	17.75							Fee Schedule		20.2							Fee Schedule		2.03							Fee Schedule											1.97							Fee Schedule		24.57							Fee Schedule		2.27							Fee Schedule		1.84							Fee Schedule											2.27							Fee Schedule		1.84							Fee Schedule		
CLINDAMYCIN  300 MG/2 ML (CLEOCIN) VIAL	250	RC	J0736	CPT				Both			11.55	5.2	1.84	10.4	7.51							Fee Schedule		8.55							Fee Schedule		2.03							Fee Schedule											1.97							Fee Schedule		10.4							Fee Schedule		2.27							Fee Schedule		1.84							Fee Schedule											2.27							Fee Schedule		1.84							Fee Schedule		
CLINDAMYCIN  600 MG (CLEOCIN) PREMIX	250	RC	J0736	CPT				Both			39.9	17.96	1.84	35.91	25.94							Fee Schedule		29.53							Fee Schedule		2.03							Fee Schedule											1.97							Fee Schedule		35.91							Fee Schedule		2.27							Fee Schedule		1.84							Fee Schedule											2.27							Fee Schedule		1.84							Fee Schedule		
CLINDAMYCIN  600 MG/4 ML VIAL(150MG/ML)	250	RC	J0736	CPT				Both			13.07	5.88	1.84	11.76	8.5							Fee Schedule		9.67							Fee Schedule		2.03							Fee Schedule											1.97							Fee Schedule		11.76							Fee Schedule		2.27							Fee Schedule		1.84							Fee Schedule											2.27							Fee Schedule		1.84							Fee Schedule		
CLINDAMYCIN  900 MG (CLEOCIN) PREMIX	250	RC	J0736	CPT				Both			49.35	22.21	1.84	44.42	32.08							Fee Schedule		36.52							Fee Schedule		2.03							Fee Schedule											1.97							Fee Schedule		44.42							Fee Schedule		2.27							Fee Schedule		1.84							Fee Schedule											2.27							Fee Schedule		1.84							Fee Schedule		
CLINIMIX 2.75  # 2B7725	258	RC						Both			37.8	17.01	17.01	34.02	24.57							Fee Schedule		27.97							Fee Schedule																													34.02							Fee Schedule																																															
CLINIMIX 4.25/5  1000ML 2B7716	250	RC						Both			91.35	41.11	41.11	82.22	59.38							Fee Schedule		67.6							Fee Schedule																													82.22							Fee Schedule																																															
CLINIMIX 5/20  2000ML PREMIX	258	RC	B4185	CPT				Both			268.8	120.96	7.22	241.92	7.22							Fee Schedule		198.91							Fee Schedule																													241.92							Fee Schedule																																															
CLINIMIX 8/14  2000ML PREMIX	258	RC	B4185	CPT				Both			392.7	176.72	7.22	353.43	7.22							Fee Schedule		290.6							Fee Schedule																													353.43							Fee Schedule																																															
CLINIMIX-E (W/ELECTROLYTES) 5/20 2000ML	258	RC	A9270	CPT				Both			313.17	140.93	0.01	281.85	0.01							Fee Schedule		231.75							Fee Schedule																													281.85							Fee Schedule																																															
CLOBETASOL PROP 0.05% CR30GM(TEMOVATE)	250	RC	A9270	CPT				Both			100.8	45.36	0.01	90.72	0.01							Fee Schedule		74.59							Fee Schedule																													90.72							Fee Schedule																																															
CLOMIPRAMINE 30013 ANAFRANIL 2ML SERUM	301	RC	80299	CPT				Both			165.9	74.66	13.42	149.31	13.42							Fee Schedule		18.64							Fee Schedule		19.2							Fee Schedule		18.64							Fee Schedule		18.64							Fee Schedule		149.31							Fee Schedule		21.44							Fee Schedule		17.34							Fee Schedule		18.64							Fee Schedule		21.44							Fee Schedule		17.34							Fee Schedule		
clonazePAM (KLONOPIN) 0.5 MG TABLET	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
clonazePAM (KLONOPIN) 1 MG TABLET	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
CloNIDine 0.1MG (CATAPRES) TABLET	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
CloNIDine 0.2MG (CATAPRES) TABLET	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
CloNIDine 0.3MG (CATAPRES) TABLET	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
CLONIDINE TTS 0.1 MG  PATCH	250	RC	A9270	CPT				Both			103.95	46.78	0.01	93.56	0.01							Fee Schedule		76.92							Fee Schedule																													93.56							Fee Schedule																																															
CLONIDINE TTS 0.2 MG  PATCH	250	RC	A9270	CPT				Both			136.92	61.61	0.01	123.23	0.01							Fee Schedule		101.32							Fee Schedule																													123.23							Fee Schedule																																															
CLONIDINE TTS 0.3 MG  PATCH	250	RC	A9270	CPT				Both			276.15	124.27	0.01	248.54	0.01							Fee Schedule		204.35							Fee Schedule																													248.54							Fee Schedule																																															
CLONOPIN SERUM 340 CLONAZEPAM	300	RC	80307	CPT				Both			315	141.75	51.72	283.5	51.72							Fee Schedule		64.65							Fee Schedule		64							Fee Schedule		62.14							Fee Schedule		62.14							Fee Schedule		283.5							Fee Schedule		71.46							Fee Schedule		57.79							Fee Schedule		62.14							Fee Schedule		71.46							Fee Schedule		57.79							Fee Schedule		
CLONOPIN URINE 40064 CLONAZEPAM 10ML URI	301	RC	80307	CPT				Both			210	94.5	51.72	189	51.72							Fee Schedule		64.65							Fee Schedule		64							Fee Schedule		62.14							Fee Schedule		62.14							Fee Schedule		189							Fee Schedule		71.46							Fee Schedule		57.79							Fee Schedule		62.14							Fee Schedule		71.46							Fee Schedule		57.79							Fee Schedule		
CLORAZEPATE 7.5 MG TABLET UD	250	RC	A9270	CPT				Both			5.78	2.6	0.01	5.2	0.01							Fee Schedule		4.28							Fee Schedule																													5.2							Fee Schedule																																															
CLORPACTIN wcs-90	250	RC						Both			17.85	8.03	8.03	16.07	11.6							Fee Schedule		13.21							Fee Schedule																													16.07							Fee Schedule																																															
CLORPACTIN WCS-90 2GM PACKET	250	RC						Both			14.7	6.62	6.62	13.23	9.56							Fee Schedule		10.88							Fee Schedule																													13.23							Fee Schedule																																															
CLOSED WOUND KIT 0072430(BARD MEDICAL)	272	RC						Both			36	16.2	16.2	32.4	23.4							Fee Schedule		26.64							Fee Schedule																													32.4							Fee Schedule																																															
CLOSTRIDIUM DIFFICILE 91664  A & B TOXIN	306	RC	87324	CPT				Both			69.3	31.19	10.66	62.37	10.66							Fee Schedule		13.32							Fee Schedule		12.34							Fee Schedule		11.98							Fee Schedule		11.98							Fee Schedule		62.37							Fee Schedule		13.78							Fee Schedule		11.14							Fee Schedule		11.98							Fee Schedule		13.78							Fee Schedule		11.14							Fee Schedule		
CLOSTRIDIUM DIFFICILE AG INHOUSE	306	RC	87803	CPT				Both			114.45	51.5	11.52	103.01	11.52							Fee Schedule		16							Fee Schedule		16.48							Fee Schedule		16							Fee Schedule		16							Fee Schedule		103.01							Fee Schedule		18.4							Fee Schedule		14.88							Fee Schedule		16							Fee Schedule		18.4							Fee Schedule		14.88							Fee Schedule		
CLOSTRIDIUM DIFFICILE ANTIBODY NEU 34403	306	RC	87230	CPT				Both			221.85	99.83	17.55	199.67	17.55							Fee Schedule		21.93							Fee Schedule		20.33							Fee Schedule		19.74							Fee Schedule		19.74							Fee Schedule		199.67							Fee Schedule		22.7							Fee Schedule		18.36							Fee Schedule		19.74							Fee Schedule		22.7							Fee Schedule		18.36							Fee Schedule		
CLOTEST	272	RC						Both			25.2	11.34	11.34	22.68	16.38							Fee Schedule		18.65							Fee Schedule																													22.68							Fee Schedule																																															
CLOTRIM/BETAMETHASONE 1%/0.05% CREAM-15G	250	RC	A9270	CPT				Both			72.45	32.6	0.01	65.21	0.01							Fee Schedule		53.61							Fee Schedule																													65.21							Fee Schedule																																															
CLOTRIMAZOLE 1% TOPICAL CREAM 15GM	250	RC	A9270	CPT				Both			26.25	11.81	0.01	23.63	0.01							Fee Schedule		19.43							Fee Schedule																													23.63							Fee Schedule																																															
CLOTRIMAZOLE 1% VAGINAL CR -7 DAY	250	RC	A9270	CPT				Both			42	18.9	0.01	37.8	0.01							Fee Schedule		31.08							Fee Schedule																													37.8							Fee Schedule																																															
CLOTRIMAZOLE 1% VAGINAL CREAM-45GM	250	RC	A9270	CPT				Both			25.2	11.34	0.01	22.68	0.01							Fee Schedule		18.65							Fee Schedule																													22.68							Fee Schedule																																															
CLOTRIMAZOLE 10 MG TROCHE (MYCELEX)	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
CLOTTING FAC II 331	305	RC	85210	CPT				Both			131.25	59.06	11.54	118.13	11.54							Fee Schedule		14.43							Fee Schedule		13.37							Fee Schedule		12.98							Fee Schedule		12.98							Fee Schedule		118.13							Fee Schedule		14.93							Fee Schedule		12.07							Fee Schedule		12.98							Fee Schedule		14.93							Fee Schedule		12.07							Fee Schedule		
CLOTTING FAC IX 352	305	RC	85250	CPT				Both			206.85	93.08	16.93	186.17	16.93							Fee Schedule		21.16							Fee Schedule		19.61							Fee Schedule		19.04							Fee Schedule		19.04							Fee Schedule		186.17							Fee Schedule		21.9							Fee Schedule		17.71							Fee Schedule		19.04							Fee Schedule		21.9							Fee Schedule		17.71							Fee Schedule		
CLOTTING FAC V 344	305	RC	85220	CPT				Both			284.55	128.05	15.69	256.1	15.69							Fee Schedule		19.61							Fee Schedule		18.18							Fee Schedule		17.65							Fee Schedule		17.65							Fee Schedule		256.1							Fee Schedule		20.3							Fee Schedule		16.41							Fee Schedule		17.65							Fee Schedule		20.3							Fee Schedule		16.41							Fee Schedule		
CLOTTING FAC V LEIDEN 17900 EDTA	310	RC	81241	CPT				Both			373.8	168.21	54.32	336.42	54.32							Fee Schedule		73.37							Fee Schedule		75.57							Fee Schedule		73.37							Fee Schedule		73.37							Fee Schedule		336.42							Fee Schedule		84.38							Fee Schedule		68.23							Fee Schedule											84.38							Fee Schedule		68.23							Fee Schedule		
CLOTTING FAC VII 346	305	RC	85230	CPT				Both			131.25	59.06	15.91	118.13	15.91							Fee Schedule		19.89							Fee Schedule		18.44							Fee Schedule		17.9							Fee Schedule		17.9							Fee Schedule		118.13							Fee Schedule		20.59							Fee Schedule		16.65							Fee Schedule		17.9							Fee Schedule		20.59							Fee Schedule		16.65							Fee Schedule		
CLOTTING FAC VIII 347	305	RC	85240	CPT				Both			206.85	93.08	15.91	186.17	15.91							Fee Schedule		19.89							Fee Schedule		18.44							Fee Schedule		17.9							Fee Schedule		17.9							Fee Schedule		186.17							Fee Schedule		20.59							Fee Schedule		16.65							Fee Schedule		17.9							Fee Schedule		20.59							Fee Schedule		16.65							Fee Schedule		
CLOTTING FAC X 359	305	RC	85260	CPT				Both			131.25	59.06	15.91	118.13	15.91							Fee Schedule		19.89							Fee Schedule		18.44							Fee Schedule		17.9							Fee Schedule		17.9							Fee Schedule		118.13							Fee Schedule		20.59							Fee Schedule		16.65							Fee Schedule		17.9							Fee Schedule		20.59							Fee Schedule		16.65							Fee Schedule		
CLOTTING FAC XI 360	305	RC	85270	CPT				Both			149.1	67.1	15.91	134.19	15.91							Fee Schedule		19.89							Fee Schedule		18.44							Fee Schedule		17.9							Fee Schedule		17.9							Fee Schedule		134.19							Fee Schedule		20.59							Fee Schedule		16.65							Fee Schedule		17.9							Fee Schedule		20.59							Fee Schedule		16.65							Fee Schedule		
CLOTTING FAC XII 362	305	RC	85280	CPT				Both			149.1	67.1	17.2	134.19	17.2							Fee Schedule		21.5							Fee Schedule		19.93							Fee Schedule		19.35							Fee Schedule		19.35							Fee Schedule		134.19							Fee Schedule		22.25							Fee Schedule		18							Fee Schedule		19.35							Fee Schedule		22.25							Fee Schedule		18							Fee Schedule		
CLOZA NORCLOZAPINE 1769	301	RC	82542	CPT				Both			159.6	71.82	17.34	143.64	17.34							Fee Schedule		24.09							Fee Schedule		24.81							Fee Schedule		24.09							Fee Schedule		24.09							Fee Schedule		143.64							Fee Schedule		27.7							Fee Schedule		22.4							Fee Schedule		24.09							Fee Schedule		27.7							Fee Schedule		22.4							Fee Schedule		
CMV CYTOMEGALOVIRIS IGM 8503	302	RC	86645	CPT				Both			84	37.8	14.98	75.6	14.98							Fee Schedule		18.72							Fee Schedule		17.36							Fee Schedule		16.85							Fee Schedule		16.85							Fee Schedule		75.6							Fee Schedule		19.38							Fee Schedule		15.67							Fee Schedule		16.85							Fee Schedule		19.38							Fee Schedule		15.67							Fee Schedule		
CMV CYTOMEGALOVIRUS IGG 403	302	RC	86644	CPT				Both			78.75	35.44	12.79	70.88	12.79							Fee Schedule		15.99							Fee Schedule		14.82							Fee Schedule		14.39							Fee Schedule		14.39							Fee Schedule		70.88							Fee Schedule		16.55							Fee Schedule		13.38							Fee Schedule		14.39							Fee Schedule		16.55							Fee Schedule		13.38							Fee Schedule		
CMV DNA BY PCR 10600 PLASMA 1ML	302	RC	86645	CPT				Both			171.15	77.02	14.98	154.04	14.98							Fee Schedule		18.72							Fee Schedule		17.36							Fee Schedule		16.85							Fee Schedule		16.85							Fee Schedule		154.04							Fee Schedule		19.38							Fee Schedule		15.67							Fee Schedule		16.85							Fee Schedule		19.38							Fee Schedule		15.67							Fee Schedule		
CMV DNA BY PCR 10600 URINE 1ML	302	RC	86645	CPT				Both			171.15	77.02	14.98	154.04	14.98							Fee Schedule		18.72							Fee Schedule		17.36							Fee Schedule		16.85							Fee Schedule		16.85							Fee Schedule		154.04							Fee Schedule		19.38							Fee Schedule		15.67							Fee Schedule		16.85							Fee Schedule		19.38							Fee Schedule		15.67							Fee Schedule		
CO2	301	RC	82374	CPT				Both			114.45	51.5	4.34	103.01	4.34							Fee Schedule		5.43							Fee Schedule		5.03							Fee Schedule		4.88							Fee Schedule		4.88							Fee Schedule		103.01							Fee Schedule		5.61							Fee Schedule		4.54							Fee Schedule		4.88							Fee Schedule		5.61							Fee Schedule		4.54							Fee Schedule		
CO2 DETECTOR FOR AMBU BAG CPRM2400	272	RC						Both			33	14.85	14.85	29.7	21.45							Fee Schedule		24.42							Fee Schedule																													29.7							Fee Schedule																																															
CO2 DETECTOR PEDIATRIC # PEDICAP6	272	RC						Both			31	13.95	13.95	27.9	20.15							Fee Schedule		22.94							Fee Schedule																													27.9							Fee Schedule																																															
CO2 DETECTOR PEDI-CAP 8-5140-01	272	RC						Both			31	13.95	13.95	27.9	20.15							Fee Schedule		22.94							Fee Schedule																													27.9							Fee Schedule																																															
CO2 FILTER LINE INSUFFLATION	272	RC						Both			44.1	19.85	19.85	39.69	28.67							Fee Schedule		32.63							Fee Schedule																													39.69							Fee Schedule																																															
INTERSTITIAL LUNG DISEASE WITH CC					197	DRG		Inpatient			17927.19	8067.24	8067.24	8067.24							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period							0		No services provided during 15 month lookback period				5335.18	5335.18	5335.18	1 through 10									0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period	
COBALT 35417 4ML WHOLE BLOOD ROYAL BLUE	300	RC	83018	CPT				Both			100.8	45.36	19.53	90.72	19.53							Fee Schedule		24.41							Fee Schedule		22.62							Fee Schedule		21.96							Fee Schedule		21.96							Fee Schedule		90.72							Fee Schedule		25.25							Fee Schedule		20.42							Fee Schedule		21.96							Fee Schedule		25.25							Fee Schedule		20.42							Fee Schedule		
COBAN 2  NONSTERILE PRM088002	270	RC	A6453	CPT				Both			2	0.9	0.53	1.8	0.56							Fee Schedule		1.48							Fee Schedule		0.93							Fee Schedule		0.53							Fee Schedule		0.9							Fee Schedule		1.8							Fee Schedule		1.04							Fee Schedule		0.84							Fee Schedule											1.04							Fee Schedule		0.84							Fee Schedule		
COBAN 2  SHORT ROLL #PRM088002S	270	RC	A6453	CPT				Both			1	0.45	0.45	1.04	0.56							Fee Schedule		0.74							Fee Schedule		0.93							Fee Schedule		0.53							Fee Schedule		0.9							Fee Schedule		0.9							Fee Schedule		1.04							Fee Schedule		0.84							Fee Schedule											1.04							Fee Schedule		0.84							Fee Schedule		
COBAN 2 LITE SYSTEM #2794N	270	RC						Both			33	14.85	14.85	29.7	21.45							Fee Schedule		24.42							Fee Schedule																													29.7							Fee Schedule																																															
COBAN 3  NONSTERILE PRM088003	270	RC						Both			3	1.35	1.35	2.7	1.95							Fee Schedule		2.22							Fee Schedule																													2.7							Fee Schedule																																															
COBAN 3  STERILE NON-LATEX 2083S	272	RC	A6454	CPT				Both			6	2.7	0.67	5.4	0.7							Fee Schedule		4.44							Fee Schedule		1.15							Fee Schedule		0.67							Fee Schedule		1.12							Fee Schedule		5.4							Fee Schedule		1.29							Fee Schedule		1.04							Fee Schedule											1.29							Fee Schedule		1.04							Fee Schedule		
COBAN 4  NONSTERILE #PRM088004	270	RC	A6454	CPT				Both			3	1.35	0.67	2.7	0.7							Fee Schedule		2.22							Fee Schedule		1.15							Fee Schedule		0.67							Fee Schedule		1.12							Fee Schedule		2.7							Fee Schedule		1.29							Fee Schedule		1.04							Fee Schedule											1.29							Fee Schedule		1.04							Fee Schedule		
COBAN 4  STERILE LATEX FREE 2084S	272	RC						Both			7	3.15	3.15	6.3	4.55							Fee Schedule		5.18							Fee Schedule																													6.3							Fee Schedule																																															
COBAN 6  STERILE LATEX FREE 2086S	272	RC						Both			10	4.5	4.5	9	6.5							Fee Schedule		7.4							Fee Schedule																													9							Fee Schedule																																															
COBAN LATEX FREE 2086S	272	RC	A6455	CPT				Both			10	4.5	1.21	9	1.26							Fee Schedule		7.4							Fee Schedule		2.05							Fee Schedule		1.21							Fee Schedule		1.99							Fee Schedule		9							Fee Schedule		2.29							Fee Schedule		1.85							Fee Schedule											2.29							Fee Schedule		1.85							Fee Schedule		
CO-BAN TAPE FOR P.T.	271	RC						Both			3.15	1.42	1.42	2.84	2.05							Fee Schedule		2.33							Fee Schedule																													2.84							Fee Schedule																																															
COCAINE 4% NASAL SOLUTION- 4ML BOTTLE	250	RC	C9046	CPT				Both			926.1	416.75	1.53	833.49	1.53							Fee Schedule		685.31							Fee Schedule																													833.49							Fee Schedule																																															
"COCAINE SCREEN, SER/PLASMA 26568"	301	RC	80307	CPT				Both			201	90.45	51.72	180.9	51.72							Fee Schedule		64.65							Fee Schedule		64							Fee Schedule		62.14							Fee Schedule		62.14							Fee Schedule		180.9							Fee Schedule		71.46							Fee Schedule		57.79							Fee Schedule		62.14							Fee Schedule		71.46							Fee Schedule		57.79							Fee Schedule		
COCCIDIOIDES AB 906 SERUM	302	RC	86635	CPT				Both			63	28.35	10.2	56.7	10.2							Fee Schedule		12.75							Fee Schedule		11.81							Fee Schedule		11.47							Fee Schedule		11.47							Fee Schedule		56.7							Fee Schedule		13.19							Fee Schedule		10.67							Fee Schedule		11.47							Fee Schedule		13.19							Fee Schedule		10.67							Fee Schedule		
COCCYX & SACRUM 2V MIN	320	RC	72220	CPT				Both			315	141.75	15.89	318	15.89							Fee Schedule		19.67							Fee Schedule											16.3							Fee Schedule											283.5							Fee Schedule																				318							Per Diem																				
COCOA BUTTER LOTION 11 OZ BOTTLE	250	RC	A9270	CPT				Both			6.77	3.05	0.01	6.09	0.01							Fee Schedule		5.01							Fee Schedule																													6.09							Fee Schedule																																															
CODE BLUE GASTRIC LAVAGE SYSTEM(BALLARD)	272	RC						Both			185.85	83.63	83.63	167.27	120.8							Fee Schedule		137.53							Fee Schedule																													167.27							Fee Schedule																																															
CODEINE/ASA/BUTALB/CAFF 30/325/50/40 TAB	250	RC	A9270	CPT				Both			4.46	2.01	0.01	4.01	0.01							Fee Schedule		3.3							Fee Schedule																													4.01							Fee Schedule																																															
CODIMAL DH 5ML UD	250	RC	A9270	CPT				Both			4.2	1.89	0.01	3.78	0.01							Fee Schedule		3.11							Fee Schedule																													3.78							Fee Schedule																																															
CODMAN PATTIES NEW# NEUROSPNG09	272	RC						Both			8	3.6	3.6	7.2	5.2							Fee Schedule		5.92							Fee Schedule																													7.2							Fee Schedule																																															
CODMAN SURGICAL PATTIES 801407	270	RC						Both			7	3.15	3.15	6.3	4.55							Fee Schedule		5.18							Fee Schedule																													6.3							Fee Schedule																																															
COENZYME Q10  (COQ10) QUEST 10178	301	RC	82542	CPT				Both			136.2	61.29	17.34	122.58	17.34							Fee Schedule		24.09							Fee Schedule		24.81							Fee Schedule		24.09							Fee Schedule		24.09							Fee Schedule		122.58							Fee Schedule		27.7							Fee Schedule		22.4							Fee Schedule		24.09							Fee Schedule		27.7							Fee Schedule		22.4							Fee Schedule		
COEUR ANGIOGRAPHIC SYRINGE C853-6150	272	RC						Both			13.65	6.14	6.14	12.29	8.87							Fee Schedule		10.1							Fee Schedule																													12.29							Fee Schedule																																															
COFLEX #3200 2 INCH COLOR SENECA MEDICAL	270	RC						Both			2.1	0.95	0.95	1.89	1.37							Fee Schedule		1.55							Fee Schedule																													1.89							Fee Schedule																																															
COFLEX #3300 3 INCH COLOR SENECA	270	RC						Both			3.15	1.42	1.42	2.84	2.05							Fee Schedule		2.33							Fee Schedule																													2.84							Fee Schedule																																															
COFLEX 2  COLOR PAK # 5200CP ( SENECA )	270	RC						Both			3	1.35	1.35	2.7	1.95							Fee Schedule		2.22							Fee Schedule																													2.7							Fee Schedule																																															
COFLEX 3  COLOR PAK # 5300CP ( SENECA )	270	RC						Both			3.15	1.42	1.42	2.84	2.05							Fee Schedule		2.33							Fee Schedule																													2.84							Fee Schedule																																															
COFLEX KIDS 3   5300KP-024	270	RC						Both			3.15	1.42	1.42	2.84	2.05							Fee Schedule		2.33							Fee Schedule																													2.84							Fee Schedule																																															
COFLEX KIDS PAK # 5200KP (DISC.)	270	RC						Both			3.68	1.66	1.66	3.31	2.39							Fee Schedule		2.72							Fee Schedule																													3.31							Fee Schedule																																															
COLCRYS 0.6 MG (COLCHICINE) TAB	250	RC	A9270	CPT				Both			18.9	8.51	0.01	17.01	0.01							Fee Schedule		13.99							Fee Schedule																													17.01							Fee Schedule																																															
COLD AGGLUTININS 349 3 ML SERUM	302	RC	86157	CPT				Both			57.75	25.99	7.16	51.98	7.16							Fee Schedule		8.96							Fee Schedule		8.3							Fee Schedule		8.06							Fee Schedule		8.06							Fee Schedule		51.98							Fee Schedule		9.27							Fee Schedule		7.5							Fee Schedule		8.06							Fee Schedule		9.27							Fee Schedule		7.5							Fee Schedule		
COLD PACK PLOYURETHANE 610690-001	270	RC						Both			68.78	30.95	30.95	61.9	44.71							Fee Schedule		50.9							Fee Schedule																													61.9							Fee Schedule																																															
COLD PRESS #11440-900	270	RC	A9273	CPT				Both			1	0.45	0.45	6.27	6.27							Fee Schedule		0.74							Fee Schedule																													0.9							Fee Schedule																																															
COLD SPOT PILLOW # 505 ( BEEKLEY MEDICAL	270	RC	A9273	CPT				Both			13	5.85	5.85	11.7	6.27							Fee Schedule		9.62							Fee Schedule																													11.7							Fee Schedule																																															
COLD THERAPY CUBE W/ KNEE PAD #10707	270	RC						Both			530.25	238.61	238.61	477.23	344.66							Fee Schedule		392.39							Fee Schedule																													477.23							Fee Schedule																																															
COLISTIMETHATE SODIUM 150MG/100ML IVPB	636	RC	J0743	CPT				Both			32.13	14.46	6.06	28.92		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	23.78							Fee Schedule		6.71							Fee Schedule		17.1							Fee Schedule		6.52							Fee Schedule		28.92							Fee Schedule		7.49							Fee Schedule		6.06							Fee Schedule											7.49							Fee Schedule		6.06							Fee Schedule		
COLL SET	272	RC						Both			19.95	8.98	8.98	17.96	12.97							Fee Schedule		14.76							Fee Schedule																													17.96							Fee Schedule																																															
COLLAGEN PROMOGRAN DSG. 4X4 # PG004	272	RC						Both			29.4	13.23	13.23	26.46	19.11							Fee Schedule		21.76							Fee Schedule																													26.46							Fee Schedule																																															
COLLAGENASE OINTMENT- 30 GM	250	RC	A9270	CPT				Both			892.5	401.63	0.01	803.25	0.01							Fee Schedule		660.45							Fee Schedule																													803.25							Fee Schedule																																															
COLLOIDAL OATMEAL 100% PACKET	250	RC						Both			17.59	7.92	7.92	15.83	11.43							Fee Schedule		13.02							Fee Schedule																													15.83							Fee Schedule																																															
COLOCORT 100 MG/60ML RETENTION ENEMA	250	RC	A9270	CPT				Both			38.85	17.48	0.01	34.97	0.01							Fee Schedule		28.75							Fee Schedule																													34.97							Fee Schedule																																															
COLOPLAST 1-PIECE STER. OSTOMY BAG 18680	272	RC	A4424	CPT				Both			2	0.9	0.9	7.8	4.29							Fee Schedule		1.48							Fee Schedule		6.98							Fee Schedule		4.14							Fee Schedule		6.78							Fee Schedule		1.8							Fee Schedule		7.8							Fee Schedule		6.31							Fee Schedule											7.8							Fee Schedule		6.31							Fee Schedule		
COLOPLAST COLLAG INJ.SYST NEEDLE 890209	272	RC						Both			94.5	42.53	42.53	85.05	61.43							Fee Schedule		69.93							Fee Schedule																													85.05							Fee Schedule																																															
COLOPLAST COLLAGEN IMPLANT #890215	274	RC	L8603	CPT				Both			765.45	344.45	344.45	688.91		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	566.43							Fee Schedule		553.02							Fee Schedule		416.46							Fee Schedule		536.91							Fee Schedule		688.91							Fee Schedule		617.45							Fee Schedule		499.33							Fee Schedule											617.45							Fee Schedule		499.33							Fee Schedule		
COLOPLAST OSTOMY PASTE 12050	270	RC	A4406	CPT				Both			9	4.05	4.05	9.38	5.15							Fee Schedule		6.66							Fee Schedule		8.4							Fee Schedule											8.16							Fee Schedule		8.1							Fee Schedule		9.38							Fee Schedule		7.59							Fee Schedule											9.38							Fee Schedule		7.59							Fee Schedule		
COLOPLAST SENSURA COLO BAG 12273 RED	274	RC	A4425	CPT				Both			10	4.5	3.12	9		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	7.4							Fee Schedule		5.25							Fee Schedule		3.12							Fee Schedule		5.1							Fee Schedule		9							Fee Schedule		5.87							Fee Schedule		4.74							Fee Schedule											5.87							Fee Schedule		4.74							Fee Schedule		
COLOPLAST SENSURA COLO BAG 12283 YELLOW	274	RC	A4425	CPT				Both			10	4.5	3.12	9		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	7.4							Fee Schedule		5.25							Fee Schedule		3.12							Fee Schedule		5.1							Fee Schedule		9							Fee Schedule		5.87							Fee Schedule		4.74							Fee Schedule											5.87							Fee Schedule		4.74							Fee Schedule		
COLOPLAST SENSURA FLAT BARRIER 10561 RED	274	RC	A4410	CPT				Both			6	2.7	2.7	14.81		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	4.44							Fee Schedule		13.27							Fee Schedule											12.88							Fee Schedule		5.4							Fee Schedule		14.81							Fee Schedule		11.98							Fee Schedule											14.81							Fee Schedule		11.98							Fee Schedule		
COLOPLAST SENSURA FLAT BARRIER 10571 YEL	274	RC	A4410	CPT				Both			6	2.7	2.7	14.81		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	4.44							Fee Schedule		13.27							Fee Schedule											12.88							Fee Schedule		5.4							Fee Schedule		14.81							Fee Schedule		11.98							Fee Schedule											14.81							Fee Schedule		11.98							Fee Schedule		
COLOPLAST SENSURA UROSTOMY BAG 12298 RED	274	RC	A5073	CPT				Both			10	4.5	3.4	9		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	7.4							Fee Schedule		4.43							Fee Schedule		3.4							Fee Schedule		4.3							Fee Schedule		9							Fee Schedule		4.95							Fee Schedule		4							Fee Schedule											4.95							Fee Schedule		4							Fee Schedule		
COLORS GAS FAL 370 EASH	271	RC						Both			10.5	4.73	4.73	9.45	6.83							Fee Schedule		7.77							Fee Schedule																													9.45							Fee Schedule																																															
COLOST BAGS 380Y EACH	271	RC						Both			6.3	2.84	2.84	5.67	4.1							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
COLOSTOMY BAG 1 3/4 H.H. 18192	274	RC	A4425	CPT				Both			2.5	1.13	1.13	5.87		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1.85							Fee Schedule		5.25							Fee Schedule		3.12							Fee Schedule		5.1							Fee Schedule		2.25							Fee Schedule		5.87							Fee Schedule		4.74							Fee Schedule											5.87							Fee Schedule		4.74							Fee Schedule		
COLOSTOMY BAG 2 1/4 18193	274	RC	A4425	CPT				Both			37	16.65	3.12	33.3		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	27.38							Fee Schedule		5.25							Fee Schedule		3.12							Fee Schedule		5.1							Fee Schedule		33.3							Fee Schedule		5.87							Fee Schedule		4.74							Fee Schedule											5.87							Fee Schedule		4.74							Fee Schedule		
COLOSTOMY BAG 2 1/4 H.H. 3803	274	RC	A4425	CPT				Both			2.15	0.97	0.97	5.87		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1.59							Fee Schedule		5.25							Fee Schedule		3.12							Fee Schedule		5.1							Fee Schedule		1.94							Fee Schedule		5.87							Fee Schedule		4.74							Fee Schedule											5.87							Fee Schedule		4.74							Fee Schedule		
COLOSTOMY BAG 2 3/4 18194	274	RC	A4425	CPT				Both			37	16.65	3.12	33.3		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	27.38							Fee Schedule		5.25							Fee Schedule		3.12							Fee Schedule		5.1							Fee Schedule		33.3							Fee Schedule		5.87							Fee Schedule		4.74							Fee Schedule											5.87							Fee Schedule		4.74							Fee Schedule		
COLOSTOMY BAG 2 3/4 H.H. 3804	274	RC	A4425	CPT				Both			1.35	0.61	0.61	5.87		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1							Fee Schedule		5.25							Fee Schedule		3.12							Fee Schedule		5.1							Fee Schedule		1.22							Fee Schedule		5.87							Fee Schedule		4.74							Fee Schedule											5.87							Fee Schedule		4.74							Fee Schedule		
COLOSTOMY BAG 4	274	RC	A4425	CPT				Both			58.6	26.37	3.12	52.74		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	43.36							Fee Schedule		5.25							Fee Schedule		3.12							Fee Schedule		5.1							Fee Schedule		52.74							Fee Schedule		5.87							Fee Schedule		4.74							Fee Schedule											5.87							Fee Schedule		4.74							Fee Schedule		
COLOSTOMY BAG 4 INCH (HOLLISTER)	274	RC	A4425	CPT				Both			26.25	11.81	3.12	23.63		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	19.43							Fee Schedule		5.25							Fee Schedule		3.12							Fee Schedule		5.1							Fee Schedule		23.63							Fee Schedule		5.87							Fee Schedule		4.74							Fee Schedule											5.87							Fee Schedule		4.74							Fee Schedule		
COLOSTOMY FLANGE 1 3/4 H.H. 14602	274	RC	A4409	CPT				Both			4.35	1.96	1.96	10.17		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	3.22							Fee Schedule		9.11							Fee Schedule											8.84							Fee Schedule		3.92							Fee Schedule		10.17							Fee Schedule		8.22							Fee Schedule											10.17							Fee Schedule		8.22							Fee Schedule		
COLOSTOMY FLANGE 2 1/4 14103	274	RC	A4373	CPT				Both			25	11.25	8.31	22.5		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	18.5							Fee Schedule		9.21							Fee Schedule											8.94							Fee Schedule		22.5							Fee Schedule		10.28							Fee Schedule		8.31							Fee Schedule											10.28							Fee Schedule		8.31							Fee Schedule		
COLOSTOMY FLANGE 2 1/4 14603	274	RC	A4409	CPT				Both			25	11.25	8.22	22.5		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	18.5							Fee Schedule		9.11							Fee Schedule											8.84							Fee Schedule		22.5							Fee Schedule		10.17							Fee Schedule		8.22							Fee Schedule											10.17							Fee Schedule		8.22							Fee Schedule		
COLOSTOMY FLANGE 2 1/4 H.H. 3703	274	RC	A4373	CPT				Both			3.35	1.51	1.51	10.28		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	2.48							Fee Schedule		9.21							Fee Schedule											8.94							Fee Schedule		3.02							Fee Schedule		10.28							Fee Schedule		8.31							Fee Schedule											10.28							Fee Schedule		8.31							Fee Schedule		
COLOSTOMY FLANGE 2 3/4 14604  PURCHASING	274	RC	A4409	CPT				Both			25	11.25	8.22	22.5		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	18.5							Fee Schedule		9.11							Fee Schedule											8.84							Fee Schedule		22.5							Fee Schedule		10.17							Fee Schedule		8.22							Fee Schedule											10.17							Fee Schedule		8.22							Fee Schedule		
COLOSTOMY FLANGE 2 3/4 H.H. 3704	274	RC	A4373	CPT				Both			2.1	0.95	0.95	10.28		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1.55							Fee Schedule		9.21							Fee Schedule											8.94							Fee Schedule		1.89							Fee Schedule		10.28							Fee Schedule		8.31							Fee Schedule											10.28							Fee Schedule		8.31							Fee Schedule		
COLOSTOMY FLANGE 2-3/4 14104	272	RC	A4409	CPT				Both			25	11.25	5.6	22.5	5.6							Fee Schedule		18.5							Fee Schedule		9.11							Fee Schedule											8.84							Fee Schedule		22.5							Fee Schedule		10.17							Fee Schedule		8.22							Fee Schedule											10.17							Fee Schedule		8.22							Fee Schedule		
COLOSTOMY FLANGE 4	274	RC	A4388	CPT				Both			31.5	14.18	5.78	28.35		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	23.31							Fee Schedule		6.4							Fee Schedule											6.21							Fee Schedule		28.35							Fee Schedule		7.14							Fee Schedule		5.78							Fee Schedule											7.14							Fee Schedule		5.78							Fee Schedule		
COLOSTOMY FLANGE 4 INCH (HOLLISTER)	274	RC	A4416	CPT				Both			85.05	38.27	2.4	76.55		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	62.94							Fee Schedule		4.05							Fee Schedule		2.4							Fee Schedule		3.93							Fee Schedule		76.55							Fee Schedule		4.52							Fee Schedule		3.65							Fee Schedule											4.52							Fee Schedule		3.65							Fee Schedule		
COLTEST HP FAST 60480	272	RC						Both			33	14.85	14.85	29.7	21.45							Fee Schedule		24.42							Fee Schedule																													29.7							Fee Schedule																																															
COMBIDERM 187725	272	RC	A6255	CPT				Both			13.65	6.14	2.74	12.29	2.74							Fee Schedule		10.1							Fee Schedule		4.47							Fee Schedule		3.42							Fee Schedule		4.34							Fee Schedule		12.29							Fee Schedule		4.99							Fee Schedule		4.04							Fee Schedule											4.99							Fee Schedule		4.04							Fee Schedule		
COMBIVENT 14.7 GM MDI	250	RC	A9270	CPT				Both			687.24	309.26	0.01	618.52	0.01							Fee Schedule		508.56							Fee Schedule																													618.52							Fee Schedule																																															
COMBIVIR 150 MG/300 MG TABLETS	250	RC	A9270	CPT				Both			50.4	22.68	0.01	45.36	0.01							Fee Schedule		37.3							Fee Schedule																													45.36							Fee Schedule																																															
COMFORT FORM WRIST/THUMB LT XS #79-87312	274	RC						Both			47.25	21.26	21.26	42.53		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	34.97							Fee Schedule																													42.53							Fee Schedule																																															
"COMFORT FORM WRIST/THUMB LT,L 79-87317"	274	RC						Both			47.25	21.26	21.26	42.53		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	34.97							Fee Schedule																													42.53							Fee Schedule																																															
"COMFORT FORM WRIST/THUMB LT,M 79-87315"	274	RC						Both			47.25	21.26	21.26	42.53		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	34.97							Fee Schedule																													42.53							Fee Schedule																																															
"COMFORT FORM WRIST/THUMB LT,S 79-87313"	274	RC						Both			47.25	21.26	21.26	42.53		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	34.97							Fee Schedule																													42.53							Fee Schedule																																															
COMFORT FORM WRIST/THUMB RT XS #79-87302	274	RC						Both			47.25	21.26	21.26	42.53		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	34.97							Fee Schedule																													42.53							Fee Schedule																																															
"COMFORT FORM WRIST/THUMB RT,L 79-87307"	274	RC	A4565	CPT				Both			47.25	21.26	8.66	42.53		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	34.97							Fee Schedule		11.31							Fee Schedule		8.66							Fee Schedule		10.98							Fee Schedule		42.53							Fee Schedule		12.63							Fee Schedule		10.21							Fee Schedule											12.63							Fee Schedule		10.21							Fee Schedule		
"COMFORT FORM WRIST/THUMB RT,M 79-87305"	274	RC	A4565	CPT				Both			47.25	21.26	8.66	42.53		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	34.97							Fee Schedule		11.31							Fee Schedule		8.66							Fee Schedule		10.98							Fee Schedule		42.53							Fee Schedule		12.63							Fee Schedule		10.21							Fee Schedule											12.63							Fee Schedule		10.21							Fee Schedule		
"COMFORT FORM WRIST/THUMB RT,S 79-87303"	274	RC						Both			47.25	21.26	21.26	42.53		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	34.97							Fee Schedule																													42.53							Fee Schedule																																															
COMPLEMENT COMPONENT C1Q  981	302	RC	86160	CPT				Both			96.24	43.31	10.66	86.62	10.66							Fee Schedule		13.33							Fee Schedule		12.36							Fee Schedule		12							Fee Schedule		12							Fee Schedule		86.62							Fee Schedule		13.8							Fee Schedule		11.16							Fee Schedule		12							Fee Schedule		13.8							Fee Schedule		11.16							Fee Schedule		
PNEUMOTHORAX WITH CC					200	DRG		Inpatient			37773.07	16997.88	16997.88	16997.88							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period							0		No services provided during 15 month lookback period				7198.85	7198.85	7198.85	1 through 10									0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period				4366	4366	4366	1 through 10									0		No services provided during 15 month lookback							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period	
BRONCHITIS AND ASTHMA WITH CC/MCC					202	DRG		Inpatient			19710.98	8869.94	8869.94	8869.94							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period				1991.27	1991.27	1991.27	1 through 10									0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period	
BRONCHITIS AND ASTHMA WITHOUT CC/MCC					203	DRG		Inpatient			14462.41	6508.08	6508.08	6508.08							0		No services performed during 15 month lookback period. 				3153.68	3153.68	3153.68	1 through 10									0		No services performed during 15 month lookback period				1503.49	1503.49	1503.49	1 through 10									0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period				3520.63	3520.63	3520.63	1 through 10									0		No services provided during 15 month lookback							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period	
RESPIRATORY SIGNS AND SYMPTOMS					204	DRG		Inpatient			29117.3	13102.79	13102.79	13102.79							0		No services performed during 15 month lookback period. 				9847.18	9847.18	9847.18	1 through 10									0		No services performed during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period	
OTHER RESPIRATORY SYSTEM DIAGNOSES WITHOUT MCC					206	DRG		Inpatient			17458.88	7856.5	7856.5	7856.5							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period				2874.31	2874.31	2874.31	1 through 10						5478.08	5478.08	5478.08	1 through 10									0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period	
COMPREHENSIVE METABOLIC PANEL CMP	301	RC	80053	CPT				Both			165.9	74.66	9.39	149.31	9.39							Fee Schedule		11.74							Fee Schedule		10.88							Fee Schedule		10.56							Fee Schedule		10.56							Fee Schedule		149.31							Fee Schedule		12.14							Fee Schedule		9.82							Fee Schedule		10.56							Fee Schedule		12.14							Fee Schedule		9.82							Fee Schedule		
COMPRESSION GLOVE MED.R.	270	RC						Both			23.1	10.4	10.4	20.79	15.02							Fee Schedule		17.09							Fee Schedule																													20.79							Fee Schedule																																															
COMPRESSION GLOVE SMALL R.	270	RC						Both			23.1	10.4	10.4	20.79	15.02							Fee Schedule		17.09							Fee Schedule																													20.79							Fee Schedule																																															
COMPRESSION SCREW	278	RC	C1713	CPT				Both			467.25	210.26	210.26	420.53		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	345.77							Fee Schedule																													420.53							Fee Schedule																																															
COMPRESSION TUBE PLATE 135 4 HOLE	278	RC						Both			1018.5	458.33	458.33	916.65		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	753.69							Fee Schedule																													916.65							Fee Schedule																																															
COMPRESSION TUBE PLATE 135 5 HOLE	278	RC						Both			1018.5	458.33	458.33	916.65		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	753.69							Fee Schedule																													916.65							Fee Schedule																																															
CONCHA COLUMN HEATER W/WATER 385-70	270	RC						Both			35.7	16.07	16.07	32.13	23.21							Fee Schedule		26.42							Fee Schedule																													32.13							Fee Schedule																																															
CONCHA COLUMN WATER ONLY   381-50	270	RC						Both			12.6	5.67	5.67	11.34	8.19							Fee Schedule		9.32							Fee Schedule																													11.34							Fee Schedule																																															
CONFORM 1	272	RC						Both			2.1	0.95	0.95	1.89	1.37							Fee Schedule		1.55							Fee Schedule																													1.89							Fee Schedule																																															
CONFORM 2	272	RC						Both			2.1	0.95	0.95	1.89	1.37							Fee Schedule		1.55							Fee Schedule																													1.89							Fee Schedule																																															
CONFORM 3	272	RC						Both			3.15	1.42	1.42	2.84	2.05							Fee Schedule		2.33							Fee Schedule																													2.84							Fee Schedule																																															
CONFORM 4	272	RC						Both			3.15	1.42	1.42	2.84	2.05							Fee Schedule		2.33							Fee Schedule																													2.84							Fee Schedule																																															
CONMED BIFURCATED TUBING  SEM-EVAC	272	RC						Both			232	104.4	104.4	208.8	150.8							Fee Schedule		171.68							Fee Schedule																													208.8							Fee Schedule																																															
CONMED SUCTION POOLE TIPS #0035040	272	RC						Both			5	2.25	2.25	4.5	3.25							Fee Schedule		3.7							Fee Schedule																													4.5							Fee Schedule																																															
CONMED ULTRA CLEAN #139100	272	RC						Both			17.85	8.03	8.03	16.07	11.6							Fee Schedule		13.21							Fee Schedule																													16.07							Fee Schedule																																															
CONMED ULTRA CLEAN #139107	272	RC						Both			19.95	8.98	8.98	17.96	12.97							Fee Schedule		14.76							Fee Schedule																													17.96							Fee Schedule																																															
CONN TUBE 3.7MM (ARGYLE) 8888301531	270	RC						Both			5	2.25	2.25	4.5	3.25							Fee Schedule		3.7							Fee Schedule																													4.5							Fee Schedule																																															
CONNECTING TUBE LG. BUSSE #1540	272	RC						Both			28.35	12.76	12.76	25.52	18.43							Fee Schedule		20.98							Fee Schedule																													25.52							Fee Schedule																																															
CONNECTING TUBE LG. DYND50216	272	RC						Both			2	0.9	0.9	1.8	1.3							Fee Schedule		1.48							Fee Schedule																													1.8							Fee Schedule																																															
CONNECTING TUBE SM DYND50211	271	RC						Both			1	0.45	0.45	0.9	0.65							Fee Schedule		0.74							Fee Schedule																													0.9							Fee Schedule																																															
CONNECTING TUBES LG	272	RC						Both			3.15	1.42	1.42	2.84	2.05							Fee Schedule		2.33							Fee Schedule																													2.84							Fee Schedule																																															
CONNECTING TUBES SM	272	RC						Both			3.15	1.42	1.42	2.84	2.05							Fee Schedule		2.33							Fee Schedule																													2.84							Fee Schedule																																															
CONNECTING TUBING 12' (OR) #71-C512	272	RC						Both			4	1.8	1.8	3.6	2.6							Fee Schedule		2.96							Fee Schedule																													3.6							Fee Schedule																																															
RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT >96 HOU					207	DRG		Inpatient			105012.57	47255.66	47255.66	47255.66							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period				1958.97	1958.97	1958.97	1 through 10						39187.45	39187.45	39187.45	1 through 10									0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period	
CONNECTIVE TISSUE HUMAN	278	RC	C1762	CPT				Both			21	9.45	9.45	18.9		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	15.54							Fee Schedule																													18.9							Fee Schedule																																															
CONNECTOR 5 IN 1 #8888271411	272	RC						Both			3	1.35	1.35	2.7	1.95							Fee Schedule		2.22							Fee Schedule																													2.7							Fee Schedule																																															
CONNECTOR Y STYLE *DISC.*	272	RC						Both			4.2	1.89	1.89	3.78	2.73							Fee Schedule		3.11							Fee Schedule																													3.78							Fee Schedule																																															
CONNEXIN 26 (GJB2) DNA 92435	302	RC	81252	CPT				Both			1760	792	72.81	1584	72.81							Fee Schedule		101.12							Fee Schedule		104.15							Fee Schedule		101.12							Fee Schedule		101.12							Fee Schedule		1584							Fee Schedule		116.29							Fee Schedule		94.04							Fee Schedule		101.12							Fee Schedule		116.29							Fee Schedule		94.04							Fee Schedule		
CONSTAVAC	272	RC						Both			147	66.15	66.15	132.3	95.55							Fee Schedule		108.78							Fee Schedule																													132.3							Fee Schedule																																															
CONSULT COMPREH REVIEW REPORT	310	RC	88325	CPT				Both			787.5	354.38	108.01	708.75	108.01							Fee Schedule		174.53							Fee Schedule											144.16							Fee Schedule											708.75							Fee Schedule																																															
CONSULT REPORT PREP SLIDES	310	RC	88323	CPT				Both			225.75	101.59	21.62	203.18	21.62							Fee Schedule		24.22							Fee Schedule											26							Fee Schedule											203.18							Fee Schedule																																															
CONSULT SLIDE	310	RC	88321	CPT				Both			165.9	74.66	60.62	149.31	60.62							Fee Schedule									Other	No Additional Reimbursement 																												149.31							Fee Schedule																																															
CONSULTATION ANES	370	RC	99251	CPT				Both			57.75	25.99	25.99	51.98	50.37							Fee Schedule		42.74							Fee Schedule																													51.98							Fee Schedule																																															
CONTOUR ERCP CANNULA #M00530850	272	RC						Both			144	64.8	64.8	129.6	93.6							Fee Schedule		106.56							Fee Schedule																													129.6							Fee Schedule																																															
CONTOUR GCS40G ( SENECA )	272	RC						Both			1569	706.05	706.05	1412.1	1019.85							Fee Schedule		1161.06							Fee Schedule																													1412.1							Fee Schedule																																															
CONTOUR URET STENT 4.8 / 5FR COOK G23312	272	RC	C2617	CPT				Both			199	89.55	89.55	189.57	189.57							Fee Schedule		147.26							Fee Schedule																													179.1							Fee Schedule																																															
CONTOUR URET STENT 8FR 24CM G23422	272	RC	C2617	CPT				Both			199	89.55	89.55	189.57	189.57							Fee Schedule		147.26							Fee Schedule																													179.1							Fee Schedule																																															
CONTOUR URET STENT 8FR 26CM G23423	272	RC	C2617	CPT				Both			199	89.55	89.55	189.57	189.57							Fee Schedule		147.26							Fee Schedule																													179.1							Fee Schedule																																															
CONTOUR URET STENT 8FR 28CM G23424	272	RC	C2617	CPT				Both			199	89.55	89.55	189.57	189.57							Fee Schedule		147.26							Fee Schedule																													179.1							Fee Schedule																																															
CONTOUR URETERAL STENT 7FR COOK G23314	272	RC	C2617	CPT				Both			199	89.55	89.55	189.57	189.57							Fee Schedule		147.26							Fee Schedule																													179.1							Fee Schedule																																															
CONTROL PUMP AMS800 SPHINCTER 72404127	278	RC	C1815	CPT				Both			23520	10584	10584	21168		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	17404.8							Fee Schedule																													21168							Fee Schedule																																															
COOK 24FR G TUBE  (G31548 & 6825 DISC)	270	RC	B4087	CPT				Both			185.85	83.63	14.31	167.27	14.31							Fee Schedule		137.53							Fee Schedule																													167.27							Fee Schedule																																															
COOK 4 WIRE BASKET #MSB-2.5X5	272	RC						Both			855.75	385.09	385.09	770.18	556.24							Fee Schedule		633.26							Fee Schedule																													770.18							Fee Schedule																																															
COOK 4 WIRE BASKET #MSB-2X4	272	RC						Both			756	340.2	340.2	680.4	491.4							Fee Schedule		559.44							Fee Schedule																													680.4							Fee Schedule																																															
COOK 4 WIRE BASKET #MSB-3X6	272	RC						Both			771.75	347.29	347.29	694.58	501.64							Fee Schedule		571.1							Fee Schedule																													694.58							Fee Schedule																																															
COOK 6 WIRE BASKET #MSB-3X6-6-D	272	RC						Both			723	325.35	325.35	650.7	469.95							Fee Schedule		535.02							Fee Schedule																													650.7							Fee Schedule																																															
COOK 8 WIRE BASKET #MB5-2X4-8	272	RC						Both			983.85	442.73	442.73	885.47	639.5							Fee Schedule		728.05							Fee Schedule																													885.47							Fee Schedule																																															
COOK 8 WIRE BASKET #MB5-2X4-8	272	RC						Both			855.75	385.09	385.09	770.18	556.24							Fee Schedule		633.26							Fee Schedule																													770.18							Fee Schedule																																															
COOK 9-SHOOTER LIGATOR G31917	272	RC						Both			680	306	306	612	442							Fee Schedule		503.2							Fee Schedule																													612							Fee Schedule																																															
COOK ACCUSNARE MINI HEX ASMH-1-S	272	RC						Both			45.15	20.32	20.32	40.64	29.35							Fee Schedule		33.41							Fee Schedule																													40.64							Fee Schedule																																															
COOK AMPLATZ RENAL DILATOR # 075000	272	RC	C1726	CPT				Both			724.5	326.03	135.94	652.05	135.94							Fee Schedule		536.13							Fee Schedule																													652.05							Fee Schedule																																															
COOK BALLOON FEEDING TUBE 18FR G35617	272	RC						Both			204	91.8	91.8	183.6	132.6							Fee Schedule		150.96							Fee Schedule																													183.6							Fee Schedule																																															
COOK BALLOON FEEDING TUBE 20FR G35618	272	RC						Both			214.2	96.39	96.39	192.78	139.23							Fee Schedule		158.51							Fee Schedule																													192.78							Fee Schedule																																															
COOK BALLOON FEEDING TUBE 24FR G35620	272	RC						Both			276	124.2	124.2	248.4	179.4							Fee Schedule		204.24							Fee Schedule																													248.4							Fee Schedule																																															
COOK BENTSON GUIDE WIRE TSFBP-35-180	272	RC						Both			52.5	23.63	23.63	47.25	34.13							Fee Schedule		38.85							Fee Schedule																													47.25							Fee Schedule																																															
COOK BILI. STENT INTRO SET 8.5FR BSI-8.5	272	RC						Both			337.05	151.67	151.67	303.35	219.08							Fee Schedule		249.42							Fee Schedule																													303.35							Fee Schedule																																															
COOK BILIARY STENT G13699 (DISC.)	278	RC	C2625	CPT				Both			1984.5	893.03	893.03	1786.05		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1468.53							Fee Schedule																													1786.05							Fee Schedule																																															
COOK BILIARY STENT INTRO SET 10FR BSI-10	278	RC	C2625	CPT				Both			315	141.75	141.75	283.5		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	233.1							Fee Schedule																													283.5							Fee Schedule																																															
COOK BILIARY STENT INTRO. SET 7FR BSI-7	278	RC	C1877	CPT				Both			281.4	126.63	126.63	253.26		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	208.24							Fee Schedule																													253.26							Fee Schedule																																															
COOK BOLUS FEEDING ADAPTER BFA-24-S	272	RC						Both			24.15	10.87	10.87	21.74	15.7							Fee Schedule		17.87							Fee Schedule																													21.74							Fee Schedule																																															
COOK CALIBRATED TIP WIRE GUIDE G47616	272	RC	C1769	CPT				Both			560.7	252.32	154.26	504.63	154.26							Fee Schedule		414.92							Fee Schedule																													504.63							Fee Schedule																																															
COOK CAPTURA HOT BIOPSY G56135	272	RC						Both			68.25	30.71	30.71	61.43	44.36							Fee Schedule		50.51							Fee Schedule																													61.43							Fee Schedule																																															
COOK CAPTURA PRO BIOPSY G50696	272	RC						Both			55	24.75	24.75	49.5	35.75							Fee Schedule		40.7							Fee Schedule																													49.5							Fee Schedule																																															
COOK CERVICAL RIPENING BALLOON G19891	272	RC	C1726	CPT				Both			127	57.15	57.15	135.94	135.94							Fee Schedule		93.98							Fee Schedule																													114.3							Fee Schedule																																															
COOK CHEST DRAIN VALUE G36370	272	RC	C1729	CPT				Both			227	102.15	13.87	204.3	13.87							Fee Schedule		167.98							Fee Schedule																													204.3							Fee Schedule																																															
COOK CODA BALLON CATH G03832	272	RC	C1725	CPT				Both			1354.5	609.53	93.3	1219.05	93.3							Fee Schedule		1002.33							Fee Schedule																													1219.05							Fee Schedule																																															
COOK COTT. HUIB BILI STENT	278	RC	C2617	CPT				Both			165	74.25	74.25	148.5		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	122.1							Fee Schedule																													148.5							Fee Schedule																																															
COOK COTT. HUIB BILI STENT #CHBSO-10-12	278	RC	C2617	CPT				Both			165	74.25	74.25	148.5		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	122.1							Fee Schedule																													148.5							Fee Schedule																																															
COOK COTT. HUIB BILI STENT #CHBSO-10-5	278	RC	C2617	CPT				Both			189	85.05	85.05	170.1		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	139.86							Fee Schedule																													170.1							Fee Schedule																																															
COOK COTT. HUIB BILI STENT #CHBSO-10-7	278	RC	C2617	CPT				Both			165	74.25	74.25	148.5		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	122.1							Fee Schedule																													148.5							Fee Schedule																																															
COOK COTT. HUIB BILI STENT #CHBSO-10-9	278	RC	C2617	CPT				Both			189	85.05	85.05	170.1		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	139.86							Fee Schedule																													170.1							Fee Schedule																																															
COOK COTT. HUIB BILI STENT #CHBSO-7-12	278	RC	C1877	CPT				Both			173.25	77.96	77.96	155.93		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	128.21							Fee Schedule																													155.93							Fee Schedule																																															
COOK COTT. HUIB BILI STENT #CHBSO-7-7	278	RC	C2617	CPT				Both			189	85.05	85.05	170.1		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	139.86							Fee Schedule																													170.1							Fee Schedule																																															
COOK COTT. HUIB BILI STENT #CHBSO-7-9	278	RC	C2617	CPT				Both			168	75.6	75.6	151.2		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	124.32							Fee Schedule																													151.2							Fee Schedule																																															
COOK COTT. HUIB BILI STENT #CHBSO-8.5-12	278	RC	C1877	CPT				Both			173.25	77.96	77.96	155.93		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	128.21							Fee Schedule																													155.93							Fee Schedule																																															
COOK COTT. HUIB BILI STENT #CHBSO-8.5-7	278	RC	C2617	CPT				Both			220.5	99.23	99.23	198.45		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	163.17							Fee Schedule																													198.45							Fee Schedule																																															
COOK COTT. HUIB BILI STENT #CHBSO-8.5-9	278	RC	C1877	CPT				Both			168	75.6	75.6	151.2		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	124.32							Fee Schedule																													151.2							Fee Schedule																																															
COOK COTTON HUIB STENT 10FR/5 CHBS-10-5	278	RC	C1877	CPT				Both			354.9	159.71	159.71	319.41		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	262.63							Fee Schedule																													319.41							Fee Schedule																																															
COOK COTTON HUIB STENT 10FR/7 CHBS-10-7	278	RC	C1877	CPT				Both			333	149.85	149.85	299.7		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	246.42							Fee Schedule																													299.7							Fee Schedule																																															
COOK COTTON HUIB STENT 10FR/9 CHBS-10-9	278	RC	C1877	CPT				Both			333	149.85	149.85	299.7		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	246.42							Fee Schedule																													299.7							Fee Schedule																																															
COOK CYTOMAX II DUAL LUMEN #DLB-35-3.5-S	272	RC						Both			283.5	127.58	127.58	255.15	184.28							Fee Schedule		209.79							Fee Schedule																													255.15							Fee Schedule																																															
COOK DASH TRIP EXTRACT BASKET DASH-2X2.5	272	RC						Both			725.55	326.5	326.5	653	471.61							Fee Schedule		536.91							Fee Schedule																													653							Fee Schedule																																															
COOK DILATION SYRINGE G27112	272	RC						Both			89.25	40.16	40.16	80.33	58.01							Fee Schedule		66.05							Fee Schedule																													80.33							Fee Schedule																																															
COOK DILATOR COONS TAPER 10FR #G03928	272	RC						Both			52	23.4	23.4	46.8	33.8							Fee Schedule		38.48							Fee Schedule																													46.8							Fee Schedule																																															
COOK DILATOR COONS TAPER 8FR #G03927	272	RC						Both			52	23.4	23.4	46.8	33.8							Fee Schedule		38.48							Fee Schedule																													46.8							Fee Schedule																																															
COOK DRAINAGE CATHETER 10.2 FR G09502	272	RC	C1729	CPT				Both			306	137.7	13.87	275.4	13.87							Fee Schedule		226.44							Fee Schedule																													275.4							Fee Schedule																																															
COOK DRAINAGE CATHETER 12FR G09767	272	RC	C1729	CPT				Both			298	134.1	13.87	268.2	13.87							Fee Schedule		220.52							Fee Schedule																													268.2							Fee Schedule																																															
COOK DRAINAGE CATHETER 14FR  G09768	272	RC	C1729	CPT				Both			306	137.7	13.87	275.4	13.87							Fee Schedule		226.44							Fee Schedule																													275.4							Fee Schedule																																															
COOK ERCP CATHETER G22093	272	RC						Both			153	68.85	68.85	137.7	99.45							Fee Schedule		113.22							Fee Schedule																													137.7							Fee Schedule																																															
COOK ESOPHAGEAL STENT    G51181	278	RC	C1874	CPT				Both			4882.5	2197.13	2197.13	4394.25		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	3613.05							Fee Schedule																													4394.25							Fee Schedule																																															
COOK ESOPHAGEAL STENT    G51183	278	RC	C1874	CPT				Both			4882.5	2197.13	2197.13	4394.25		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	3613.05							Fee Schedule																													4394.25							Fee Schedule																																															
COOK ESOPHAGEAL STENT    G57365	278	RC	C1874	CPT				Both			6681	3006.45	3006.45	6012.9		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	4943.94							Fee Schedule																													6012.9							Fee Schedule																																															
COOK EXP. MET. BILI STENT #ZILBS-10-8	278	RC	C1877	CPT				Both			3539.55	1592.8	1592.8	3185.6		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	2619.27							Fee Schedule																													3185.6							Fee Schedule																																															
COOK FUSION BALLOON #FS-8.5-12-15-A	272	RC	C1726	CPT				Both			506.1	227.75	135.94	455.49	135.94							Fee Schedule		374.51							Fee Schedule																													455.49							Fee Schedule																																															
COOK FUSION BALLOON ABOVE #G48225	272	RC	C1726	CPT				Both			474	213.3	135.94	426.6	135.94							Fee Schedule		350.76							Fee Schedule																													426.6							Fee Schedule																																															
COOK FUSION BALLOON BELOW #G48226	272	RC	C1726	CPT				Both			665	299.25	135.94	598.5	135.94							Fee Schedule		492.1							Fee Schedule																													598.5							Fee Schedule																																															
COOK FUSION NEEDLE KNIFE G31539	272	RC						Both			469.35	211.21	211.21	422.42	305.08							Fee Schedule		347.32							Fee Schedule																													422.42							Fee Schedule																																															
COOK FUSION OMNI SPHINCTEROTOME G31903	272	RC						Both			879	395.55	395.55	791.1	571.35							Fee Schedule		650.46							Fee Schedule																													791.1							Fee Schedule																																															
COOK FUSION OMNI-TOME FS-OMNI  G31903	272	RC						Both			879	395.55	395.55	791.1	571.35							Fee Schedule		650.46							Fee Schedule																													791.1							Fee Schedule																																															
COOK FUSION SHORTWIRE 205CM #FSW-35	272	RC	C1769	CPT				Both			477.75	214.99	154.26	429.98	154.26							Fee Schedule		353.54							Fee Schedule																													429.98							Fee Schedule																																															
COOK FUSION WIRE LOCK #FS-WL-O-10	272	RC						Both			56.7	25.52	25.52	51.03	36.86							Fee Schedule		41.96							Fee Schedule																													51.03							Fee Schedule																																															
COOK FUSION WIRE LOCK #FS-WL-O-S	272	RC						Both			40.69	18.31	18.31	36.62	26.45							Fee Schedule		30.11							Fee Schedule																													36.62							Fee Schedule																																															
COOK G BUTTON 24 FR. 2.4CM #PASS-24-2.4	272	RC						Both			786.45	353.9	353.9	707.81	511.19							Fee Schedule		581.97							Fee Schedule																													707.81							Fee Schedule																																															
COOK G-BUTTON 24 FR. 1.7 # PASS-24-1.7	272	RC						Both			590.1	265.55	265.55	531.09	383.57							Fee Schedule		436.67							Fee Schedule																													531.09							Fee Schedule																																															
COOK GOLDBERG URETERAL ADAPTER G15030	272	RC						Both			86	38.7	38.7	77.4	55.9							Fee Schedule		63.64							Fee Schedule																													77.4							Fee Schedule																																															
COOK HAND WIRE BASKET #MWB-2X4	272	RC						Both			983.85	442.73	442.73	885.47	639.5							Fee Schedule		728.05							Fee Schedule																													885.47							Fee Schedule																																															
COOK HELICAL EXTRACTOR #MWB5-1.5X3.5	272	RC						Both			855.75	385.09	385.09	770.18	556.24							Fee Schedule		633.26							Fee Schedule																													770.18							Fee Schedule																																															
COOK HVY DUTY PTFE WIRE GUIDE G14260	272	RC	C1769	CPT				Both			112	50.4	50.4	154.26	154.26							Fee Schedule		82.88							Fee Schedule																													100.8							Fee Schedule																																															
COOK INJECTION NEEDLE 25GA G22526	272	RC						Both			119.7	53.87	53.87	107.73	77.81							Fee Schedule		88.58							Fee Schedule																													107.73							Fee Schedule																																															
COOK INJECTION NEEDLE 25GA G57784	272	RC						Both			155	69.75	69.75	139.5	100.75							Fee Schedule		114.7							Fee Schedule																													139.5							Fee Schedule																																															
COOK INTRODUCER KCFW-7.0-38-RB	272	RC	C1894	CPT				Both			128.1	57.65	57.65	115.29	87.34							Fee Schedule		94.79							Fee Schedule																													115.29							Fee Schedule																																															
COOK INTRODUCER RCFW-16.0P-38-RB	272	RC	C1894	CPT				Both			394	177.3	87.34	354.6	87.34							Fee Schedule		291.56							Fee Schedule																													354.6							Fee Schedule																																															
COOK JUMBO OVAL G22630	272	RC						Both			34.65	15.59	15.59	31.19	22.52							Fee Schedule		25.64							Fee Schedule																													31.19							Fee Schedule																																															
COOK KOPANS HOOK NEEDLE DKBL-20-5.0-A	272	RC	C1751	CPT				Both			68.25	30.71	30.71	69.11	69.11							Fee Schedule		50.51							Fee Schedule																													61.43							Fee Schedule																																															
COOK LUNDERQUIST GUIDE WIRE G45208	272	RC	C1769	CPT				Both			527	237.15	154.26	474.3	154.26							Fee Schedule		389.98							Fee Schedule																													474.3							Fee Schedule																																															
COOK MED KNIFE PAPPIL HUIB. NEEDLE HPC-2	272	RC						Both			519.75	233.89	233.89	467.78	337.84							Fee Schedule		384.62							Fee Schedule																													467.78							Fee Schedule																																															
COOK MEDI. ERCP PUSHING CATH #PC-3	272	RC	C1889	CPT				Both			112.35	50.56	50.56	101.12	73.03							Fee Schedule		83.14							Fee Schedule																													101.12							Fee Schedule																																															
COOK MEDI. GUIDE WIRE FS-WL-O-S	272	RC	C1769	CPT				Both			40.69	18.31	18.31	154.26	154.26							Fee Schedule		30.11							Fee Schedule																													36.62							Fee Schedule																																															
COOK MEDI. PANC. STENT #ZPSOF-5-3	278	RC	C2625	CPT				Both			169.05	76.07	76.07	152.15		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	125.1							Fee Schedule																													152.15							Fee Schedule																																															
COOK MEDI.COTT BILI STENT #CHBSO-7-12	278	RC	C2617	CPT				Both			157.5	70.88	70.88	141.75		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	116.55							Fee Schedule																													141.75							Fee Schedule																																															
COOK MEDI.COTT BILI STENT #CHBSO-7-7	278	RC	C2617	CPT				Both			173.25	77.96	77.96	155.93		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	128.21							Fee Schedule																													155.93							Fee Schedule																																															
COOK MEDI.COTT BILI STENT #CHBSO-7-9	278	RC	C2617	CPT				Both			157.5	70.88	70.88	141.75		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	116.55							Fee Schedule																													141.75							Fee Schedule																																															
COOK MEDI.ERCP CATH ERCP-1	272	RC						Both			189	85.05	85.05	170.1	122.85							Fee Schedule		139.86							Fee Schedule																													170.1							Fee Schedule																																															
COOK MEDI.JEJUNAL FEED TUBE #PEGJ-12-24	272	RC						Both			315	141.75	141.75	283.5	204.75							Fee Schedule		233.1							Fee Schedule																													283.5							Fee Schedule																																															
COOK MEDI.PANC.STENT GEENEN #GPSO-5-2	278	RC	C1877	CPT				Both			220.5	99.23	99.23	198.45		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	163.17							Fee Schedule																													198.45							Fee Schedule																																															
COOK MEDI.PANC.STENT GEENEN #GPSO-5-5	278	RC	C1877	CPT				Both			220.5	99.23	99.23	198.45		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	163.17							Fee Schedule																													198.45							Fee Schedule																																															
COOK MEDI.PANC.STENT GEENEN #GPSO-5-7	278	RC	C1877	CPT				Both			220.5	99.23	99.23	198.45		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	163.17							Fee Schedule																													198.45							Fee Schedule																																															
COOK MEDI.PANC.STENT ZIMMON #SPSOS-3-8-N	278	RC	C1877	CPT				Both			174.3	78.44	78.44	156.87		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	128.98							Fee Schedule																													156.87							Fee Schedule																																															
COOK MEDI.PANC.STENT ZIMMON #ZPSOF-5-4	278	RC	C1877	CPT				Both			178.5	80.33	80.33	160.65		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	132.09							Fee Schedule																													160.65							Fee Schedule																																															
COOK MEDI.PANC.STENT ZIMMON #ZPSOF-5-6	278	RC	C1877	CPT				Both			197.4	88.83	88.83	177.66		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	146.08							Fee Schedule																													177.66							Fee Schedule																																															
COOK MEDI.PANCREATIC STENT ZPSOF-5-2	278	RC	C1726	CPT				Both			173.25	77.96	77.96	155.93		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	128.21							Fee Schedule																													155.93							Fee Schedule																																															
COOK MEDI.PUSHING CATHETER 5 FR. PC-5	272	RC						Both			130.2	58.59	58.59	117.18	84.63							Fee Schedule		96.35							Fee Schedule																													117.18							Fee Schedule																																															
COOK MEDI.ZIMMON PANC.STENT #SPSOF-5-3	278	RC	C1877	CPT				Both			191.1	86	86	171.99		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	141.41							Fee Schedule																													171.99							Fee Schedule																																															
COOK MEDIC OASIS-ONE ACTION STENT OA-8.5	278	RC	C1876	CPT				Both			253.05	113.87	113.87	227.75		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	187.26							Fee Schedule																													227.75							Fee Schedule																																															
COOK MEDIC. OASIS-ONE ACTION STENT OA-10	278	RC	C1876	CPT				Both			253.05	113.87	113.87	227.75		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	187.26							Fee Schedule																													227.75							Fee Schedule																																															
COOK MEDIC. SIDE ARM ADAPTERS DSA-1	271	RC						Both			40.95	18.43	18.43	36.86	26.62							Fee Schedule		30.3							Fee Schedule																													36.86							Fee Schedule																																															
COOK MEDIC.EXTRACTION BASKET #WEB-2.5X5	272	RC						Both			561.75	252.79	252.79	505.58	365.14							Fee Schedule		415.7							Fee Schedule																													505.58							Fee Schedule																																															
COOK MEDIC.EXTRACTION BASKET #WEB-2X4	272	RC						Both			561.75	252.79	252.79	505.58	365.14							Fee Schedule		415.7							Fee Schedule																													505.58							Fee Schedule																																															
COOK MEDIC.EXTRACTION BASKET #WEB-3X6	272	RC						Both			561.75	252.79	252.79	505.58	365.14							Fee Schedule		415.7							Fee Schedule																													505.58							Fee Schedule																																															
COOK MEDICA. PEG-24-PUSH	272	RC						Both			539.7	242.87	242.87	485.73	350.81							Fee Schedule		399.38							Fee Schedule																													485.73							Fee Schedule																																															
COOK MEMORY BASKET # MWB5-1.5X3.5	272	RC						Both			756	340.2	340.2	680.4	491.4							Fee Schedule		559.44							Fee Schedule																													680.4							Fee Schedule																																															
COOK MEMORY BASKET 2X4CM 6 WIRE G57272	272	RC						Both			771.75	347.29	347.29	694.58	501.64							Fee Schedule		571.1							Fee Schedule																													694.58							Fee Schedule																																															
COOK MEMORY EIGHT WIRE BASKET MB5-3X6-8	272	RC	C1877	CPT				Both			910.35	409.66	409.66	819.32	657.38							Fee Schedule		673.66							Fee Schedule																													819.32							Fee Schedule																																															
COOK MEMORY HARD WIRE BASKET MWB-1.5X3.5	272	RC	C1877	CPT				Both			910.35	409.66	409.66	819.32	657.38							Fee Schedule		673.66							Fee Schedule																													819.32							Fee Schedule																																															
COOK MEMORY HARD WIRE BASKET MWB-2.5X5	272	RC	C1877	CPT				Both			910.35	409.66	409.66	819.32	657.38							Fee Schedule		673.66							Fee Schedule																													819.32							Fee Schedule																																															
COOK MEMORY HARD WIRE BASKET MWB-2X4	272	RC	C1877	CPT				Both			910.35	409.66	409.66	819.32	657.38							Fee Schedule		673.66							Fee Schedule																													819.32							Fee Schedule																																															
COOK MEMORY HARD WIRE BASKET MWB-3X6	272	RC	C1877	CPT				Both			910.35	409.66	409.66	819.32	657.38							Fee Schedule		673.66							Fee Schedule																													819.32							Fee Schedule																																															
COOK MEMORY SOFT WIRE BASKET MSB-2.5X5-F	272	RC	C1877	CPT				Both			910.35	409.66	409.66	819.32	657.38							Fee Schedule		673.66							Fee Schedule																													819.32							Fee Schedule																																															
COOK MEMORY SOFT WIRE BASKET MSB-2X4-F	272	RC	C1877	CPT				Both			910.35	409.66	409.66	819.32	657.38							Fee Schedule		673.66							Fee Schedule																													819.32							Fee Schedule																																															
COOK MEMORY SOFT WIRE BASKET MSB-3X6-F	272	RC	C1877	CPT				Both			910.35	409.66	409.66	819.32	657.38							Fee Schedule		673.66							Fee Schedule																													819.32							Fee Schedule																																															
COOK MICROPUNCTURE KIT G48004	272	RC						Both			211	94.95	94.95	189.9	137.15							Fee Schedule		156.14							Fee Schedule																													189.9							Fee Schedule																																															
COOK MICROPUNCTURE KIT MPIS-405-SST	272	RC						Both			121	54.45	54.45	108.9	78.65							Fee Schedule		89.54							Fee Schedule																													108.9							Fee Schedule																																															
COOK MINI OVAL G22633	272	RC						Both			57	25.65	25.65	51.3	37.05							Fee Schedule		42.18							Fee Schedule																													51.3							Fee Schedule																																															
COOK NEFF PERC  ACCESS SET 21G-15 G08564	272	RC	C1769	CPT				Both			264.24	118.91	118.91	237.82	154.26							Fee Schedule		195.54							Fee Schedule																													237.82							Fee Schedule																																															
COOK OMNI-TOME DOMETIP .035 #FS-OMNI	272	RC						Both			664.65	299.09	299.09	598.19	432.02							Fee Schedule		491.84							Fee Schedule																													598.19							Fee Schedule																																															
COOK OPEN END FLEX TIP CATH # 021305	272	RC						Both			42	18.9	18.9	37.8	27.3							Fee Schedule		31.08							Fee Schedule																													37.8							Fee Schedule																																															
COOK PEG 24 G22758	270	RC	B4087	CPT				Both			330	148.5	14.31	297	14.31							Fee Schedule		244.2							Fee Schedule																													297							Fee Schedule																																															
COOK PEG 24 JEJUNAL #G22639 (DISC)	272	RC	C1769	CPT				Both			495	222.75	154.26	445.5	154.26							Fee Schedule		366.3							Fee Schedule																													445.5							Fee Schedule																																															
COOK PEG 24 KIT G22635	272	RC	C1769	CPT				Both			615	276.75	154.26	553.5	154.26							Fee Schedule		455.1							Fee Schedule																													553.5							Fee Schedule																																															
COOK PEG TUBE G22636	272	RC	C1769	CPT				Both			285	128.25	128.25	256.5	154.26							Fee Schedule		210.9							Fee Schedule																													256.5							Fee Schedule																																															
COOK PERI CATH INTRO. CHG2 PICS-501-MPIS	272	RC	C1894	CPT				Both			162.75	73.24	73.24	146.48	87.34							Fee Schedule		120.44							Fee Schedule																													146.48							Fee Schedule																																															
COOK PERI VENOUS CATH CHG1 PICS-501-MPIS	272	RC	C1751	CPT				Both			143.85	64.73	64.73	129.47	69.11							Fee Schedule		106.45							Fee Schedule																													129.47							Fee Schedule																																															
COOK POSITRAP 18MM 3FR HELICAL B MWB-2X4	272	RC						Both			1011.15	455.02	455.02	910.04	657.25							Fee Schedule		748.25							Fee Schedule																													910.04							Fee Schedule																																															
COOK POSITRAP SEGURA BASKET MB5-2X4-8	272	RC						Both			771.75	347.29	347.29	694.58	501.64							Fee Schedule		571.1							Fee Schedule																													694.58							Fee Schedule																																															
COOK QUANT BILI DILAT CATH 10MM QBD-10X3	272	RC	C1726	CPT				Both			630	283.5	135.94	567	135.94							Fee Schedule		466.2							Fee Schedule																													567							Fee Schedule																																															
COOK QUANTUM BILI DILAT CATH 6MM QBD-6X3	272	RC	C1726	CPT				Both			630	283.5	135.94	567	135.94							Fee Schedule		466.2							Fee Schedule																													567							Fee Schedule																																															
COOK QUANTUM BILI DILAT CATH 8MM QBD-8X3	272	RC	C1726	CPT				Both			630	283.5	135.94	567	135.94							Fee Schedule		466.2							Fee Schedule																													567							Fee Schedule																																															
COOK QUANTUM BILI INFLAT DEVICE QBID-1	272	RC						Both			371.7	167.27	167.27	334.53	241.61							Fee Schedule		275.06							Fee Schedule																													334.53							Fee Schedule																																															
COOK ROADRUNNER GUIDEWIRE #RR-18-480	272	RC	C1769	CPT				Both			449.4	202.23	154.26	404.46	154.26							Fee Schedule		332.56							Fee Schedule																													404.46							Fee Schedule																																															
COOK ROADRUNNER GUIDEWIRE #RR-18-480A	272	RC						Both			449.4	202.23	202.23	404.46	292.11							Fee Schedule		332.56							Fee Schedule																													404.46							Fee Schedule																																															
COOK ROTATABLE RETRIEVAL NET  G57798	272	RC						Both			300	135	135	270	195							Fee Schedule		222							Fee Schedule																													270							Fee Schedule																																															
COOK SAVARY CLEANING BRUSH #SCB-1	270	RC						Both			169.05	76.07	76.07	152.15	109.88							Fee Schedule		125.1							Fee Schedule																													152.15							Fee Schedule																																															
COOK SIDE ARM ADAPTER PTBYC-RA	271	RC						Both			64	28.8	28.8	57.6	41.6							Fee Schedule		47.36							Fee Schedule																													57.6							Fee Schedule																																															
COOK SIZING CATH N5.0-35-100-P-10S-PIG-	272	RC						Both			243.08	109.39	109.39	218.77	158							Fee Schedule		179.88							Fee Schedule																													218.77							Fee Schedule																																															
COOK SIZING CATHETER G11916	272	RC						Both			266.7	120.02	120.02	240.03	173.36							Fee Schedule		197.36							Fee Schedule																													240.03							Fee Schedule																																															
COOK SOFT WIRE BASKET MSB-3X6-6	272	RC	C1877	CPT				Both			771.75	347.29	347.29	694.58	657.38							Fee Schedule		571.1							Fee Schedule																													694.58							Fee Schedule																																															
COOK SPIRAL METAL STENT7.5 SZBS-10-7.5-C	278	RC	C1877	CPT				Both			3539.55	1592.8	1592.8	3185.6		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	2619.27							Fee Schedule																													3185.6							Fee Schedule																																															
COOK STANDARD OVAL G22632	272	RC						Both			34.65	15.59	15.59	31.19	22.52							Fee Schedule		25.64							Fee Schedule																													31.19							Fee Schedule																																															
COOK STENT INTRODUCER SIS-8.5	272	RC	C1894	CPT				Both			204.75	92.14	87.34	184.28	87.34							Fee Schedule		151.52							Fee Schedule																													184.28							Fee Schedule																																															
COOK TRAC MET GUIDE WIRE #MET-25-480	272	RC	C1769	CPT				Both			405.3	182.39	154.26	364.77	154.26							Fee Schedule		299.92							Fee Schedule																													364.77							Fee Schedule																																															
COOK TRAC MET GUIDE WIRE #MET-35-480	272	RC	C1769	CPT				Both			504	226.8	154.26	453.6	154.26							Fee Schedule		372.96							Fee Schedule																													453.6							Fee Schedule																																															
COOK URETERAL CATH DUAL LUMEN AQ-022610	272	RC	C1758	CPT				Both			166	74.7	26.42	149.4	26.42							Fee Schedule		122.84							Fee Schedule																													149.4							Fee Schedule																																															
COOK URETERAL ILLUM.CATH SET #084120	272	RC						Both			534.45	240.5	240.5	481.01	347.39							Fee Schedule		395.49							Fee Schedule																													481.01							Fee Schedule																																															
COOK VENA CAVA FILTER IGTCFS-65-1	278	RC	C1880	CPT				Both			4227	1902.15	1902.15	3804.3		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	3127.98							Fee Schedule																													3804.3							Fee Schedule																																															
COOK ZA BILIARY EXP. METAL 6 ZABS-10-6-C	278	RC	C1877	CPT				Both			3539.55	1592.8	1592.8	3185.6		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	2619.27							Fee Schedule																													3185.6							Fee Schedule																																															
COOK ZA BILIARY EXP. METAL 8 ZABS-10-8-C	278	RC	C1877	CPT				Both			3539.55	1592.8	1592.8	3185.6		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	2619.27							Fee Schedule																													3185.6							Fee Schedule																																															
COOL MIST VAPORIZER	271	RC						Both			94.5	42.53	42.53	85.05	61.43							Fee Schedule		69.93							Fee Schedule																													85.05							Fee Schedule																																															
COOMBS DIRECT	300	RC	86880	CPT				Both			43.05	19.37	4.79	38.75	4.79							Fee Schedule		5.99							Fee Schedule		5.55							Fee Schedule		5.39							Fee Schedule		5.39							Fee Schedule		38.75							Fee Schedule		6.2							Fee Schedule		5.01							Fee Schedule		5.39							Fee Schedule		6.2							Fee Schedule		5.01							Fee Schedule		
COOMBS INDIRECT	302	RC	86886	CPT				Both			43.05	19.37	4.6	38.75	4.6							Fee Schedule		5.75							Fee Schedule		5.34							Fee Schedule		5.18							Fee Schedule		5.18							Fee Schedule		38.75							Fee Schedule		5.96							Fee Schedule		4.82							Fee Schedule		5.18							Fee Schedule		5.96							Fee Schedule		4.82							Fee Schedule		
COPEPTIN   QUEST 37740	301	RC	86255	CPT				Both			411.9	185.36	10.71	370.71	10.71							Fee Schedule		13.39							Fee Schedule		12.41							Fee Schedule		12.05							Fee Schedule		12.05							Fee Schedule		370.71							Fee Schedule		13.86							Fee Schedule		11.21							Fee Schedule		12.05							Fee Schedule		13.86							Fee Schedule		11.21							Fee Schedule		
COPPER 363 2ML ROYAL BLUE - EDTA	301	RC	82525	CPT				Both			54.6	24.57	11.03	49.14	11.03							Fee Schedule		13.79							Fee Schedule		12.78							Fee Schedule		12.41							Fee Schedule		12.41							Fee Schedule		49.14							Fee Schedule		14.27							Fee Schedule		11.54							Fee Schedule		12.41							Fee Schedule		14.27							Fee Schedule		11.54							Fee Schedule		
"COPPER, BLD 35378 ROYAL BLUE"	301	RC	82525	CPT				Both			147	66.15	11.03	132.3	11.03							Fee Schedule		13.79							Fee Schedule		12.78							Fee Schedule		12.41							Fee Schedule		12.41							Fee Schedule		132.3							Fee Schedule		14.27							Fee Schedule		11.54							Fee Schedule		12.41							Fee Schedule		14.27							Fee Schedule		11.54							Fee Schedule		
"COPPER, RBC 3481"	301	RC	82525	CPT				Both			165	74.25	11.03	148.5	11.03							Fee Schedule		13.79							Fee Schedule		12.78							Fee Schedule		12.41							Fee Schedule		12.41							Fee Schedule		148.5							Fee Schedule		14.27							Fee Schedule		11.54							Fee Schedule		12.41							Fee Schedule		14.27							Fee Schedule		11.54							Fee Schedule		
CORD CLAMP DOUBLE GRIP #DYNJ04220	272	RC						Both			1	0.45	0.45	0.9	0.65							Fee Schedule		0.74							Fee Schedule																													0.9							Fee Schedule																																															
CORDIS AVANTI INTRODUCER SHEATH 402606X	272	RC	C1894	CPT				Both			66.15	29.77	29.77	87.34	87.34							Fee Schedule		48.95							Fee Schedule																													59.54							Fee Schedule																																															
CORDIS AVANTI INTRODUCER SHEATH 402607X	272	RC	C1894	CPT				Both			66.15	29.77	29.77	87.34	87.34							Fee Schedule		48.95							Fee Schedule																													59.54							Fee Schedule																																															
CORDIS AVANTI INTRODUCER SHEATH 402608X	272	RC	C1894	CPT				Both			23	10.35	10.35	87.34	87.34							Fee Schedule		17.02							Fee Schedule																													20.7							Fee Schedule																																															
CORDIS BRITE TIP 5FR SHEATH 401-011M	272	RC	C1894	CPT				Both			33	14.85	14.85	87.34	87.34							Fee Schedule		24.42							Fee Schedule																													29.7							Fee Schedule																																															
CORDIS BRITE TIP 5FR SHEATH 401-511M	272	RC	C1894	CPT				Both			33	14.85	14.85	87.34	87.34							Fee Schedule		24.42							Fee Schedule																													29.7							Fee Schedule																																															
CORDIS BRITE TIP 6FR SHEATH 401-611M	272	RC	C1894	CPT				Both			33	14.85	14.85	87.34	87.34							Fee Schedule		24.42							Fee Schedule																													29.7							Fee Schedule																																															
CORDIS BRITE TIP 8FR SHEATH 401-811M	272	RC	C1894	CPT				Both			34.65	15.59	15.59	87.34	87.34							Fee Schedule		25.64							Fee Schedule																													31.19							Fee Schedule																																															
CORDIS POWERFLEX PTA CATHETER 4400604S	272	RC	C1725	CPT				Both			1023.75	460.69	93.3	921.38	93.3							Fee Schedule		757.58							Fee Schedule																													921.38							Fee Schedule																																															
CORDIS POWERFLEX PTA CATHETER 4401008S	272	RC	C1725	CPT				Both			1023.75	460.69	93.3	921.38	93.3							Fee Schedule		757.58							Fee Schedule																													921.38							Fee Schedule																																															
CORDIS POWERFLEX PTA CATHETER 4401206S	272	RC	C1725	CPT				Both			1023.75	460.69	93.3	921.38	93.3							Fee Schedule		757.58							Fee Schedule																													921.38							Fee Schedule																																															
CORDIS SMART BILIARY STENT C14080MB	278	RC	C1876	CPT				Both			2567.25	1155.26	1155.26	2310.53		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1899.77							Fee Schedule																													2310.53							Fee Schedule																																															
CORDIS VASC. MYNX CLOSURE DEVICE MX6760	278	RC	C1760	CPT				Both			677.25	304.76	304.76	609.53		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	501.17							Fee Schedule																													609.53							Fee Schedule																																															
CORDIS VISTA BRITE CATHETER 67021055	272	RC	C1887	CPT				Both			174.3	78.44	43.86	156.87	43.86							Fee Schedule		128.98							Fee Schedule																													156.87							Fee Schedule																																															
CORDIS VISTA BRITE TIP CATHETER 67021055	272	RC	C1887	CPT				Both			174.3	78.44	43.86	156.87	43.86							Fee Schedule		128.98							Fee Schedule																													156.87							Fee Schedule																																															
CORE IRRIGATION CASSETTE #5290-075-000	272	RC						Both			209	94.05	94.05	188.1	135.85							Fee Schedule		154.66							Fee Schedule																													188.1							Fee Schedule																																															
CORFLEX POST-OP KNEE BRACE 75-7500-000	274	RC						Both			378	170.1	170.1	340.2		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	279.72							Fee Schedule																													340.2							Fee Schedule																																															
CORFLOW FEEDING TUBE #8884721255	272	RC	B4081	CPT				Both			35	15.75	8.26	31.5	8.26							Fee Schedule		25.9							Fee Schedule											25.63							Fee Schedule											31.5							Fee Schedule																																															
CORRECTOL TAB	250	RC	A9270	CPT				Both			5.25	2.36	0.01	4.73	0.01							Fee Schedule		3.89							Fee Schedule																													4.73							Fee Schedule																																															
CORRUGATED TUBING 1680 CORR-A-FLEX	271	RC	A7010	CPT				Both			7	3.15	3.15	23.21	12.61							Fee Schedule		5.18							Fee Schedule		20.79							Fee Schedule											20.18							Fee Schedule		6.3							Fee Schedule		23.21							Fee Schedule		18.77							Fee Schedule											23.21							Fee Schedule		18.77							Fee Schedule		
CORTICAL 3.5	278	RC						Both			24.15	10.87	10.87	21.74		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	17.87							Fee Schedule																													21.74							Fee Schedule																																															
CORTICOSTERONE 6547 1 ML SERUM	301	RC	82528	CPT				Both			126	56.7	20.02	113.4	20.02							Fee Schedule		25.02							Fee Schedule		23.2							Fee Schedule		22.52							Fee Schedule		22.52							Fee Schedule		113.4							Fee Schedule		25.9							Fee Schedule		20.94							Fee Schedule		22.52							Fee Schedule		25.9							Fee Schedule		20.94							Fee Schedule		
CORTISOL     QUEST 367	301	RC	82533	CPT				Both			98.7	44.42	14.49	88.83	14.49							Fee Schedule		18.11							Fee Schedule		16.79							Fee Schedule		16.3							Fee Schedule		16.3							Fee Schedule		88.83							Fee Schedule		18.75							Fee Schedule		15.16							Fee Schedule		16.3							Fee Schedule		18.75							Fee Schedule		15.16							Fee Schedule		
CORTISOL FREE URINE RANDOM 90582 2ML	301	RC	82530	CPT				Both			186.9	84.11	14.85	168.21	14.85							Fee Schedule		18.57							Fee Schedule		17.21							Fee Schedule		16.71							Fee Schedule		16.71							Fee Schedule		168.21							Fee Schedule		19.22							Fee Schedule		15.54							Fee Schedule		16.71							Fee Schedule		19.22							Fee Schedule		15.54							Fee Schedule		
CORTISOL SALIVA 19897  0.5 ML SALIVA	301	RC	82530	CPT				Both			57.75	25.99	14.85	51.98	14.85							Fee Schedule		18.57							Fee Schedule		17.21							Fee Schedule		16.71							Fee Schedule		16.71							Fee Schedule		51.98							Fee Schedule		19.22							Fee Schedule		15.54							Fee Schedule		16.71							Fee Schedule		19.22							Fee Schedule		15.54							Fee Schedule		
CORTISOL URINE 24 HR 11280  10 ML REF	301	RC	82530	CPT				Both			186.9	84.11	14.85	168.21	14.85							Fee Schedule		18.57							Fee Schedule		17.21							Fee Schedule		16.71							Fee Schedule		16.71							Fee Schedule		168.21							Fee Schedule		19.22							Fee Schedule		15.54							Fee Schedule		16.71							Fee Schedule		19.22							Fee Schedule		15.54							Fee Schedule		
"CORTISOL, FREE AND TOTAL SERUM 37077"	301	RC	82530	CPT				Both			224.1	100.85	14.85	201.69	14.85							Fee Schedule		18.57							Fee Schedule		17.21							Fee Schedule		16.71							Fee Schedule		16.71							Fee Schedule		201.69							Fee Schedule		19.22							Fee Schedule		15.54							Fee Schedule		16.71							Fee Schedule		19.22							Fee Schedule		15.54							Fee Schedule		
CORTISONE 37554 URINE 24 HR	301	RC	83789	CPT				Both			191.1	86	17.36	171.99	17.36							Fee Schedule		24.11							Fee Schedule		24.83							Fee Schedule		24.11							Fee Schedule		24.11							Fee Schedule		171.99							Fee Schedule		27.73							Fee Schedule		22.42							Fee Schedule		24.11							Fee Schedule		27.73							Fee Schedule		22.42							Fee Schedule		
CORTISPORIN TOPICAL OINTMENT	250	RC	A9270	CPT				Both			74.55	33.55	0.01	67.1	0.01							Fee Schedule		55.17							Fee Schedule																													67.1							Fee Schedule																																															
CORTROSYN 0.25 MG INJECTION	636	RC	J0834	CPT				Both			446.25	200.81	17.1	401.63		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	330.23							Fee Schedule		18.94							Fee Schedule											18.38							Fee Schedule		401.63							Fee Schedule		21.14							Fee Schedule		17.1							Fee Schedule											21.14							Fee Schedule		17.1							Fee Schedule		
CORVERT 0.1 MG/ML-10 ML SDV	636	RC	J1742	CPT				Both			1780.8	801.36	184.61	1602.72		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	298.3							Fee Schedule		204.46							Fee Schedule		232.33							Fee Schedule		198.51							Fee Schedule		1602.72							Fee Schedule		228.28							Fee Schedule		184.61							Fee Schedule											228.28							Fee Schedule		184.61							Fee Schedule		
COSENTYX 125MG/5ML VIAL	636	RC	J3247	CPT				Both			7767.03	3495.16	16.81	6990.33		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	18.04							Fee Schedule		18.62							Fee Schedule											18.07							Fee Schedule		6990.33							Fee Schedule		20.78							Fee Schedule		16.81							Fee Schedule											20.78							Fee Schedule		16.81							Fee Schedule		
COSENTYX 150MG/ML-2 SYRINGE=300MG	636	RC	J3247	CPT				Both			26672.25	12002.51	16.81	24005.03		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	18.04							Fee Schedule		18.62							Fee Schedule											18.07							Fee Schedule		24005.03							Fee Schedule		20.78							Fee Schedule		16.81							Fee Schedule											20.78							Fee Schedule		16.81							Fee Schedule		
CO-SET 93-610	272	RC						Both			58.8	26.46	26.46	52.92	38.22							Fee Schedule		43.51							Fee Schedule																													52.92							Fee Schedule																																															
CO-SET 93-610	272	RC						Both			66.15	29.77	29.77	59.54	43							Fee Schedule		48.95							Fee Schedule																													59.54							Fee Schedule																																															
COSOPT 2-0.5% OPTHL SOLUTION-5 ML	250	RC	A9270	CPT				Both			161.7	72.77	0.01	145.53	0.01							Fee Schedule		119.66							Fee Schedule																													145.53							Fee Schedule																																															
COTININE 90642 RED (NO GEL)	300	RC	80307	CPT				Both			127.05	57.17	51.72	114.35	51.72							Fee Schedule		64.65							Fee Schedule		64							Fee Schedule		62.14							Fee Schedule		62.14							Fee Schedule		114.35							Fee Schedule		71.46							Fee Schedule		57.79							Fee Schedule		62.14							Fee Schedule		71.46							Fee Schedule		57.79							Fee Schedule		
COUDE A CATH 10FR.	272	RC						Both			36.75	16.54	16.54	33.08	23.89							Fee Schedule		27.2							Fee Schedule																													33.08							Fee Schedule																																															
COUDE A CATHETER 12FR	272	RC						Both			35.7	16.07	16.07	32.13	23.21							Fee Schedule		26.42							Fee Schedule																													32.13							Fee Schedule																																															
COUDE A CATHETER 18FR	272	RC						Both			49	22.05	22.05	44.1	31.85							Fee Schedule		36.26							Fee Schedule																													44.1							Fee Schedule																																															
COUDE A CATHETER 22FR	272	RC						Both			26.25	11.81	11.81	23.63	17.06							Fee Schedule		19.43							Fee Schedule																													23.63							Fee Schedule																																															
COVAC SUCTION 50	272	RC						Both			561.75	252.79	252.79	505.58	365.14							Fee Schedule		415.7							Fee Schedule																													505.58							Fee Schedule																																															
COVAC SUCTION 90	272	RC						Both			506.1	227.75	227.75	455.49	328.97							Fee Schedule		374.51							Fee Schedule																													455.49							Fee Schedule																																															
COVAC SUCTION 90	272	RC						Both			224.7	101.12	101.12	202.23	146.06							Fee Schedule		166.28							Fee Schedule																													202.23							Fee Schedule																																															
COVADERM 4X4 #46-401  (SENECA)	272	RC	A6237	CPT				Both			6.3	2.84	2.84	12.96	7.13							Fee Schedule		4.66							Fee Schedule		11.61							Fee Schedule		8.91							Fee Schedule		11.27							Fee Schedule		5.67							Fee Schedule		12.96							Fee Schedule		10.48							Fee Schedule											12.96							Fee Schedule		10.48							Fee Schedule		
COVADERM DRESS EACH	272	RC						Both			2.1	0.95	0.95	1.89	1.37							Fee Schedule		1.55							Fee Schedule																													1.89							Fee Schedule																																															
COVIDIEN LIGASURE #LF1837	272	RC						Both			1110	499.5	499.5	999	721.5							Fee Schedule		821.4							Fee Schedule																													999							Fee Schedule																																															
COVIDIEN PROGRIP MESH LPG1510	278	RC	C1781	CPT				Both			1839	827.55	827.55	1655.1		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1360.86							Fee Schedule																													1655.1							Fee Schedule																																															
COVIDIEN STAPLER 28MM CURVED USUEEA28	272	RC						Both			3679.73	1655.88	1655.88	3311.76	2391.82							Fee Schedule		2723							Fee Schedule																													3311.76							Fee Schedule																																															
COVIDIEN TONSIL BOVIE TIP #E1455B	272	RC						Both			52	23.4	23.4	46.8	33.8							Fee Schedule		38.48							Fee Schedule																													46.8							Fee Schedule																																															
COVIDIEN V-LOC  VLOCL0615	272	RC	C1760	CPT				Both			136	61.2	61.2	122.4	114.86							Fee Schedule		100.64							Fee Schedule																													122.4							Fee Schedule																																															
COVIDIEN V-LOC  VLOCL2246	272	RC	C1760	CPT				Both			192	86.4	86.4	172.8	114.86							Fee Schedule		142.08							Fee Schedule																													172.8							Fee Schedule																																															
COVIDIEN V-LOC  VLOCM0325	272	RC	C1760	CPT				Both			162	72.9	72.9	145.8	114.86							Fee Schedule		119.88							Fee Schedule																													145.8							Fee Schedule																																															
COVIDIEN V-LOC  VLOCM0644	272	RC	C1760	CPT				Both			140	63	63	126	114.86							Fee Schedule		103.6							Fee Schedule																													126							Fee Schedule																																															
COVIDIEN V-LOC  VLOCM2115	272	RC	C1760	CPT				Both			151	67.95	67.95	135.9	114.86							Fee Schedule		111.74							Fee Schedule																													135.9							Fee Schedule																																															
COVIDIEN V-LOC  VLOCM2126	272	RC	C1760	CPT				Both			192	86.4	86.4	172.8	114.86							Fee Schedule		142.08							Fee Schedule																													172.8							Fee Schedule																																															
COVIDIEN V-LOC  VLOCM2145	272	RC	C1760	CPT				Both			140	63	63	126	114.86							Fee Schedule		103.6							Fee Schedule																													126							Fee Schedule																																															
COVIDIEN V-LOC  VLOCN0305	272	RC	C1760	CPT				Both			121	54.45	54.45	114.86	114.86							Fee Schedule		89.54							Fee Schedule																													108.9							Fee Schedule																																															
COVIDIEN V-LOC  VLOCN0305	272	RC	C1760	CPT				Both			130	58.5	58.5	117	114.86							Fee Schedule		96.2							Fee Schedule																													117							Fee Schedule																																															
COVIDIEN V-LOC  VLOCN0325	272	RC	C1760	CPT				Both			170	76.5	76.5	153	114.86							Fee Schedule		125.8							Fee Schedule																													153							Fee Schedule																																															
COVIDIEN V-LOC  VLOCN0605	272	RC	C1760	CPT				Both			170	76.5	76.5	153	114.86							Fee Schedule		125.8							Fee Schedule																													153							Fee Schedule																																															
COVIDIEN V-LOC  VLOCN0664	272	RC	C1760	CPT				Both			101.85	45.83	45.83	114.86	114.86							Fee Schedule		75.37							Fee Schedule																													91.67							Fee Schedule																																															
COVIDIEN V-LOC 0 VLOCM2116	272	RC	C1760	CPT				Both			166	74.7	74.7	149.4	114.86							Fee Schedule		122.84							Fee Schedule																													149.4							Fee Schedule																																															
COVIDIEN V-LOC 2-0 VLOCM0315	272	RC	C1760	CPT				Both			147	66.15	66.15	132.3	114.86							Fee Schedule		108.78							Fee Schedule																													132.3							Fee Schedule																																															
COVIDIEN V-LOC 2-0 VLOCM0345	272	RC	C1760	CPT				Both			140	63	63	126	114.86							Fee Schedule		103.6							Fee Schedule																													126							Fee Schedule																																															
COVIDIEN V-LOC 2-0 VLOCM0625	272	RC	C1760	CPT				Both			162	72.9	72.9	145.8	114.86							Fee Schedule		119.88							Fee Schedule																													145.8							Fee Schedule																																															
COVIDIEN V-LOC 2-0 VLOCM0644	272	RC	C1760	CPT				Both			140	63	63	126	114.86							Fee Schedule		103.6							Fee Schedule																													126							Fee Schedule																																															
COVIDIEN V-LOC 2-0 VLOCM2205	272	RC	C1760	CPT				Both			140	63	63	126	114.86							Fee Schedule		103.6							Fee Schedule																													126							Fee Schedule																																															
COVIDIEN V-LOC 3-0 VLOCM0604	272	RC	C1760	CPT				Both			96.6	43.47	43.47	114.86	114.86							Fee Schedule		71.48							Fee Schedule																													86.94							Fee Schedule																																															
COVIDIEN V-LOC 3-0 VLOCM0614	272	RC	C1760	CPT				Both			136	61.2	61.2	122.4	114.86							Fee Schedule		100.64							Fee Schedule																													122.4							Fee Schedule																																															
COVIDIEN V-LOC 3-0 VLOCM0813	272	RC	C1760	CPT				Both			101.85	45.83	45.83	114.86	114.86							Fee Schedule		75.37							Fee Schedule																													91.67							Fee Schedule																																															
COVIDIEN V-LOC 3-0 VLOCM0814	272	RC	C1760	CPT				Both			101.85	45.83	45.83	114.86	114.86							Fee Schedule		75.37							Fee Schedule																													91.67							Fee Schedule																																															
COVIDIEN V-LOC 4-0 VLOCM1203	272	RC	C1760	CPT				Both			96.6	43.47	43.47	114.86	114.86							Fee Schedule		71.48							Fee Schedule																													86.94							Fee Schedule																																															
COVIDIEN V-LOC VLOCM2146	272	RC	C1760	CPT				Both			180	81	81	162	114.86							Fee Schedule		133.2							Fee Schedule																													162							Fee Schedule																																															
"COXSACKIE A VIRUS 37477 2,4,7,9,10,16"	302	RC	86658	CPT				Both			1.05	0.47	0.47	14.98	11.58							Fee Schedule		14.47							Fee Schedule		13.42							Fee Schedule		13.03							Fee Schedule		13.03							Fee Schedule		0.95							Fee Schedule		14.98							Fee Schedule		12.12							Fee Schedule		13.03							Fee Schedule		14.98							Fee Schedule		12.12							Fee Schedule		
COXSACKIE B (1-6) ANTIBODY VIRUS 7656	302	RC	86658	CPT				Both			1.05	0.47	0.47	14.98	11.58							Fee Schedule		14.47							Fee Schedule		13.42							Fee Schedule		13.03							Fee Schedule		13.03							Fee Schedule		0.95							Fee Schedule		14.98							Fee Schedule		12.12							Fee Schedule		13.03							Fee Schedule		14.98							Fee Schedule		12.12							Fee Schedule		
COYOTE BALLOON CATHETER H74939134402010	272	RC	C1725	CPT				Both			1200	540	93.3	1080	93.3							Fee Schedule		888							Fee Schedule																													1080							Fee Schedule																																															
COYOTE BALLOON CATHETER H74939186202210	272	RC	C1725	CPT				Both			1620	729	93.3	1458	93.3							Fee Schedule		1198.8							Fee Schedule																													1458							Fee Schedule																																															
COYOTE BALLOON CATHETER H74939186300810	272	RC	C1725	CPT				Both			1200	540	93.3	1080	93.3							Fee Schedule		888							Fee Schedule																													1080							Fee Schedule																																															
COYOTE BALLOON CATHETER H74939186302210	272	RC	C1725	CPT				Both			1620	729	93.3	1458	93.3							Fee Schedule		1198.8							Fee Schedule																													1458							Fee Schedule																																															
CPAP AIR TUBING 6' LIGHT GRAY 14994	270	RC	A7037	CPT				Both			6	2.7	2.7	16.99	9.23							Fee Schedule		4.44							Fee Schedule		15.21							Fee Schedule											14.77							Fee Schedule		5.4							Fee Schedule		16.99							Fee Schedule		13.74							Fee Schedule											16.99							Fee Schedule		13.74							Fee Schedule		
CPAP CANNULAIDE SECUREMENT DEVICE CA101	270	RC						Both			20	9	9	18	13							Fee Schedule		14.8							Fee Schedule																													18							Fee Schedule																																															
CPAP CANNULAIDE SECUREMENT DEVICE CA102	270	RC						Both			20	9	9	18	13							Fee Schedule		14.8							Fee Schedule																													18							Fee Schedule																																															
CPAP CANNULAIDE SECUREMENT DEVICE CA103	270	RC						Both			20	9	9	18	13							Fee Schedule		14.8							Fee Schedule																													18							Fee Schedule																																															
CPAP CANNULAIDE SECUREMENT DEVICE CA104	270	RC						Both			20	9	9	18	13							Fee Schedule		14.8							Fee Schedule																													18							Fee Schedule																																															
CPAP CHIN STRAP BLACK #AC302175B	270	RC	A7036	CPT				Both			33	14.85	8.32	29.7	8.32							Fee Schedule		24.42							Fee Schedule		13.72							Fee Schedule											13.32							Fee Schedule		29.7							Fee Schedule		15.32							Fee Schedule		12.39							Fee Schedule											15.32							Fee Schedule		12.39							Fee Schedule		
CPAP CHIN STRAP WHITE #AC302425	270	RC	A7036	CPT				Both			53	23.85	8.32	47.7	8.32							Fee Schedule		39.22							Fee Schedule		13.72							Fee Schedule											13.32							Fee Schedule		47.7							Fee Schedule		15.32							Fee Schedule		12.39							Fee Schedule											15.32							Fee Schedule		12.39							Fee Schedule		
CPAP INITIAL	410	RC	94660	CPT				Both			283.5	127.58	48.41	286	175							Per Diem		209.79							Fee Schedule											48.41							Fee Schedule											255.15							Fee Schedule																				286							Case Rate																				
CPAP STD TUBING #SL-UN100	270	RC	A7037	CPT				Both			6	2.7	2.7	16.99	9.23							Fee Schedule		4.44							Fee Schedule		15.21							Fee Schedule											14.77							Fee Schedule		5.4							Fee Schedule		16.99							Fee Schedule		13.74							Fee Schedule											16.99							Fee Schedule		13.74							Fee Schedule		
CPAP TUBING 10FT #MCT10	270	RC	A7037	CPT				Both			21	9.45	9.23	18.9	9.23							Fee Schedule		15.54							Fee Schedule		15.21							Fee Schedule											14.77							Fee Schedule		18.9							Fee Schedule		16.99							Fee Schedule		13.74							Fee Schedule											16.99							Fee Schedule		13.74							Fee Schedule		
CPK	301	RC	82550	CPT				Both			80.85	36.38	5.79	72.77	5.79							Fee Schedule		7.23							Fee Schedule		6.71							Fee Schedule		6.51							Fee Schedule		6.51							Fee Schedule		72.77							Fee Schedule		7.49							Fee Schedule		6.05							Fee Schedule		6.51							Fee Schedule		7.49							Fee Schedule		6.05							Fee Schedule		
CPK ISOENZYMES CKMB	301	RC	82552	CPT				Both			124.95	56.23	11.9	112.46	11.9							Fee Schedule		14.88							Fee Schedule		13.79							Fee Schedule		13.39							Fee Schedule		13.39							Fee Schedule		112.46							Fee Schedule		15.4							Fee Schedule		12.45							Fee Schedule		13.39							Fee Schedule		15.4							Fee Schedule		12.45							Fee Schedule		
CPM KIT	270	RC						Both			126	56.7	56.7	113.4	81.9							Fee Schedule		93.24							Fee Schedule																													113.4							Fee Schedule																																															
CPR	480	RC	92950	CPT				Both			1123.5	505.58	200.05	1035	600							Per Diem		831.39							Fee Schedule											200.05							Fee Schedule											1011.15							Fee Schedule																				1035							Per Diem																				
CPT INITIAL	410	RC	94667	CPT				Both			283.5	127.58	17.94	286	175							Per Diem		209.79							Fee Schedule											17.94							Fee Schedule											255.15							Fee Schedule																				286							Case Rate																				
CPT SUB	410	RC	94668	CPT				Both			283.5	127.58	10.69	286	175							Per Diem		209.79							Fee Schedule											10.69							Fee Schedule											255.15							Fee Schedule																				286							Case Rate																				
CQUR MESH 10X14 31540  (ATRIUM MEDICAL)	278	RC	C1781	CPT				Both			4756.5	2140.43	2140.43	4280.85		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	3519.81							Fee Schedule																													4280.85							Fee Schedule																																															
CQUR MESH 10X14 31540 (ATRIUM)	278	RC	C1781	CPT				Both			4756.5	2140.43	2140.43	4280.85		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	3519.81							Fee Schedule																													4280.85							Fee Schedule																																															
CQUR MESH 6X8 31533 (ATRIUM MEDICAL)	278	RC	C1781	CPT				Both			2031.75	914.29	914.29	1828.58		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1503.5							Fee Schedule																													1828.58							Fee Schedule																																															
CQUR MESH 9X9 31543 (ATRIUM MEDICAL)	278	RC	C1781	CPT				Both			897.75	403.99	403.99	807.98		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	664.34							Fee Schedule																													807.98							Fee Schedule																																															
CRADLE BOOTS MEDLINE #NON081445 (FLOORS)	271	RC	E0191	CPT				Both			52	23.4	6.69	46.8	6.69							Fee Schedule		38.48							Fee Schedule		12.46							Fee Schedule											12.1							Fee Schedule		46.8							Fee Schedule		13.92							Fee Schedule		11.25							Fee Schedule											13.92							Fee Schedule		11.25							Fee Schedule		
CRAGG-MCNAMARA 4F INFUSION CATH 41033-01	272	RC	C1751	CPT				Both			324	145.8	69.11	291.6	69.11							Fee Schedule		239.76							Fee Schedule																													291.6							Fee Schedule																																															
CRAGG-MCNAMARA 4F INFUSION CATH 41042-01	272	RC	C1751	CPT				Both			324	145.8	69.11	291.6	69.11							Fee Schedule		239.76							Fee Schedule																													291.6							Fee Schedule																																															
CRAGG-MCNAMARA 5F INFUSION CATH 41048-01	272	RC	C1751	CPT				Both			294	132.3	69.11	264.6	69.11							Fee Schedule		217.56							Fee Schedule																													264.6							Fee Schedule																																															
CRAGG-MCNAMARA 5F INFUSION CATH 41060-01	272	RC	C1751	CPT				Both			456	205.2	69.11	410.4	69.11							Fee Schedule		337.44							Fee Schedule																													410.4							Fee Schedule																																															
CRANBERRY 405 MG CAPSULE UD	250	RC	A9270	CPT				Both			4.2	1.89	0.01	3.78	0.01							Fee Schedule		3.11							Fee Schedule																													3.78							Fee Schedule																																															
RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT <=96 HO					208	DRG		Inpatient			53554.46	24099.51	24099.51	24099.51							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period				8195.8	8195.8	8195.8	1 through 10									0		No services provided during 15 month lookback							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period	
AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIM					239	DRG		Inpatient			100096.81	45043.56	45043.56	45043.56							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period	
CRE FIXED BALLOON CATHETER #M00558350	272	RC						Both			586	263.7	263.7	527.4	380.9							Fee Schedule		433.64							Fee Schedule																													527.4							Fee Schedule																																															
CRE FIXED BALLOON CATHETER #M00558360	272	RC	C1726	CPT				Both			586	263.7	135.94	527.4	135.94							Fee Schedule		433.64							Fee Schedule																													527.4							Fee Schedule																																															
CRE FIXED WIRE #M00558370	272	RC	C1726	CPT				Both			586	263.7	135.94	527.4	135.94							Fee Schedule		433.64							Fee Schedule																													527.4							Fee Schedule																																															
CRE FIXED WIRE #M00558380	272	RC	C1726	CPT				Both			586	263.7	135.94	527.4	135.94							Fee Schedule		433.64							Fee Schedule																													527.4							Fee Schedule																																															
CRE FIXED WIRE 8-10MM CATHETER M00558340	272	RC	C1726	CPT				Both			586	263.7	135.94	527.4	135.94							Fee Schedule		433.64							Fee Schedule																													527.4							Fee Schedule																																															
CRE FIXED WIRE DILATOR #M00558330	272	RC						Both			337.05	151.67	151.67	303.35	219.08							Fee Schedule		249.42							Fee Schedule																													303.35							Fee Schedule																																															
CRE FIXED WIRE DILATOR #M00558340	272	RC						Both			586	263.7	263.7	527.4	380.9							Fee Schedule		433.64							Fee Schedule																													527.4							Fee Schedule																																															
CRE PRO BALLOON CATH #M00558600	272	RC						Both			668	300.6	300.6	601.2	434.2							Fee Schedule		494.32							Fee Schedule																													601.2							Fee Schedule																																															
CRE PRO BALLOON DILATOR #M00550630	272	RC						Both			119	53.55	53.55	107.1	77.35							Fee Schedule		88.06							Fee Schedule																													107.1							Fee Schedule																																															
"CREATININE CLEARANCE, 24 HOUR URINE"	301	RC	82575	CPT				Both			45.15	20.32	8.4	40.64	8.4							Fee Schedule		10.51							Fee Schedule		9.74							Fee Schedule		9.46							Fee Schedule		9.46							Fee Schedule		40.64							Fee Schedule		10.88							Fee Schedule		8.8							Fee Schedule		9.46							Fee Schedule		10.88							Fee Schedule		8.8							Fee Schedule		
CREATININE SERUM	301	RC	82565	CPT				Both			57.75	25.99	4.56	51.98	4.56							Fee Schedule		5.69							Fee Schedule		5.27							Fee Schedule		5.12							Fee Schedule		5.12							Fee Schedule		51.98							Fee Schedule		5.89							Fee Schedule		4.76							Fee Schedule		5.12							Fee Schedule		5.89							Fee Schedule		4.76							Fee Schedule		
CREATININE URINE	301	RC	82570	CPT				Both			45.15	20.32	4.6	40.64	4.6							Fee Schedule		5.75							Fee Schedule		5.34							Fee Schedule		5.18							Fee Schedule		5.18							Fee Schedule		40.64							Fee Schedule		5.96							Fee Schedule		4.82							Fee Schedule		5.18							Fee Schedule		5.96							Fee Schedule		4.82							Fee Schedule		
"CREON (24,000) CAP"	250	RC	A9270	CPT				Both			23.1	10.4	0.01	20.79	0.01							Fee Schedule		17.09							Fee Schedule																													20.79							Fee Schedule																																															
CRESENTRIC BLADE 417	272	RC						Both			112.35	50.56	50.56	101.12	73.03							Fee Schedule		83.14							Fee Schedule																													101.12							Fee Schedule																																															
CRIB DAILY PER DAY	170	RC						Inpatient			787.5	354.38	354.38	4562	500							Per Diem		1842							Per Diem									Other	Base Rate DRG Payment								Other	Base Rate DRG Payment								Other	DRG Base Rate	708.75							Fee Schedule									Other	DRG Base Rate								Other	DRG Base Rate	4562							Per Diem									Other	DRG Base Rate								Other	DRG Base Rate	
CROLOM 4% OPTH SOL	250	RC	A9270	CPT				Both			153.3	68.99	0.01	137.97	0.01							Fee Schedule		113.44							Fee Schedule																													137.97							Fee Schedule																																															
CROMOLYN (INTAL)- RT	636	RC	J7631	CPT				Both			5.25	2.36	0.64	4.73		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	3.89							Fee Schedule		0.71							Fee Schedule											0.69							Fee Schedule		4.73							Fee Schedule		0.79							Fee Schedule		0.64							Fee Schedule											0.79							Fee Schedule		0.64							Fee Schedule		
CROMOLYN SODIUM INHALER 14.2G	636	RC	J3535	CPT				Both			415.74	187.08	187.08	374.17		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	307.65							Fee Schedule																													374.17							Fee Schedule																																															
CROTALIDAE IMMUNE FAB (CROFAB) 1 GM INJ	636	RC	J0840	CPT				Both			11512.8	5180.76	1698.66	10361.52		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1841.02							Fee Schedule		1881.31							Fee Schedule											1826.52							Fee Schedule		10361.52							Fee Schedule		2100.5							Fee Schedule		1698.66							Fee Schedule											2100.5							Fee Schedule		1698.66							Fee Schedule		
CROUP TENT CANOPY (TRI-ANIM)	270	RC						Both			19.95	8.98	8.98	17.96	12.97							Fee Schedule		14.76							Fee Schedule																													17.96							Fee Schedule																																															
CRP C REACTIVE PROTEIN SERUM	302	RC	86140	CPT				Both			36.75	16.54	4.6	33.08	4.6							Fee Schedule		5.75							Fee Schedule		5.34							Fee Schedule		5.18							Fee Schedule		5.18							Fee Schedule		33.08							Fee Schedule		5.96							Fee Schedule		4.82							Fee Schedule		5.18							Fee Schedule		5.96							Fee Schedule		4.82							Fee Schedule		
CRUTCHES CHILD 4'-4'6  #G53314-8	270	RC	E0114	CPT				Both			46	20.7	20.7	75.81	36.44							Fee Schedule		34.04							Fee Schedule		67.9							Fee Schedule											65.92							Fee Schedule		41.4							Fee Schedule		75.81							Fee Schedule		61.31							Fee Schedule											75.81							Fee Schedule		61.31							Fee Schedule		
CRUTCHES LG ADULT 5'10 -6'6  #MDSV80534	270	RC	E0114	CPT				Both			54	24.3	24.3	75.81	36.44							Fee Schedule		39.96							Fee Schedule		67.9							Fee Schedule											65.92							Fee Schedule		48.6							Fee Schedule		75.81							Fee Schedule		61.31							Fee Schedule											75.81							Fee Schedule		61.31							Fee Schedule		
CRUTCHES SM ADULT 5'2 -5'10  #MDSV80535	270	RC	E0114	CPT				Both			50	22.5	22.5	75.81	36.44							Fee Schedule		37							Fee Schedule		67.9							Fee Schedule											65.92							Fee Schedule		45							Fee Schedule		75.81							Fee Schedule		61.31							Fee Schedule											75.81							Fee Schedule		61.31							Fee Schedule		
CRUTCHES YOUTH 4'6 -5'2  #MDSV80536	270	RC	E0114	CPT				Both			46	20.7	20.7	75.81	36.44							Fee Schedule		34.04							Fee Schedule		67.9							Fee Schedule											65.92							Fee Schedule		41.4							Fee Schedule		75.81							Fee Schedule		61.31							Fee Schedule											75.81							Fee Schedule		61.31							Fee Schedule		
CRYOFIBRINOGEN 376  6ML  LIGHT BLUE TUBE	302	RC	82585	CPT				Both			52.5	23.63	10.18	47.25	10.18							Fee Schedule		14.14							Fee Schedule		14.56							Fee Schedule		14.14							Fee Schedule		14.14							Fee Schedule		47.25							Fee Schedule		16.26							Fee Schedule		13.15							Fee Schedule		14.14							Fee Schedule		16.26							Fee Schedule		13.15							Fee Schedule		
CRYOGLOBULINS QUAL & QUAN 36562 SERUM	301	RC	82595	CPT				Both			85.05	38.27	5.75	76.55	5.75							Fee Schedule		7.18							Fee Schedule		6.66							Fee Schedule		6.47							Fee Schedule		6.47							Fee Schedule		76.55							Fee Schedule		7.44							Fee Schedule		6.02							Fee Schedule		6.47							Fee Schedule		7.44							Fee Schedule		6.02							Fee Schedule		
CRYOTHERAPY H KIT 2X 88ML 5701137	270	RC						Both			508	228.6	228.6	457.2	330.2							Fee Schedule		375.92							Fee Schedule																													457.2							Fee Schedule																																															
CRYOTHERAPY H KIT 88ML 5701141	270	RC						Both			633.24	284.96	284.96	569.92	411.61							Fee Schedule		468.6							Fee Schedule																													569.92							Fee Schedule																																															
CRYPTOCOCCUS AG CSF 30430 1ML	306	RC	87327	CPT				Both			88.2	39.69	10.66	79.38	10.66							Fee Schedule		13.42							Fee Schedule		13.82							Fee Schedule		13.42							Fee Schedule		13.42							Fee Schedule		79.38							Fee Schedule		15.43							Fee Schedule		12.48							Fee Schedule		13.42							Fee Schedule		15.43							Fee Schedule		12.48							Fee Schedule		
CRYPTOCOCCUS AG SERUM OR CSF 11196	302	RC	86403	CPT				Both			233.1	104.9	9.06	209.79	9.06							Fee Schedule		11.54							Fee Schedule		11.89							Fee Schedule		11.54							Fee Schedule		11.54							Fee Schedule		209.79							Fee Schedule		13.27							Fee Schedule		10.73							Fee Schedule		11.54							Fee Schedule		13.27							Fee Schedule		10.73							Fee Schedule		
"CRYPTOSPORIDIUM AG, EIA 90389 STOOL"	306	RC	87328	CPT				Both			150	67.5	10.66	135	10.66							Fee Schedule		13.82							Fee Schedule		14.23							Fee Schedule		13.82							Fee Schedule		13.82							Fee Schedule		135							Fee Schedule		15.89							Fee Schedule		12.85							Fee Schedule		13.82							Fee Schedule		15.89							Fee Schedule		12.85							Fee Schedule		
CRYSTAL IDENT SYNOVIAL  4563	309	RC	89060	CPT				Both			42	18.9	6.36	37.8	6.36							Fee Schedule		7.95							Fee Schedule		7.55							Fee Schedule		7.33							Fee Schedule		7.33							Fee Schedule		37.8							Fee Schedule		8.43							Fee Schedule		6.82							Fee Schedule		7.33							Fee Schedule		8.43							Fee Schedule		6.82							Fee Schedule		
CSF CELL COUNT W/DIFF	309	RC	89051	CPT				Both			117.6	52.92	4.9	105.84	4.9							Fee Schedule		6.12							Fee Schedule		5.77							Fee Schedule		5.6							Fee Schedule		5.6							Fee Schedule		105.84							Fee Schedule		6.44							Fee Schedule		5.21							Fee Schedule		5.6							Fee Schedule		6.44							Fee Schedule		5.21							Fee Schedule		
CSI DIAMONDBACK CART DBP-CART-125MIC145	272	RC	C1724	CPT				Both			7500	3375	525.82	6750	525.82							Fee Schedule		5550							Fee Schedule																													6750							Fee Schedule																																															
CSI DIAMONDBACK CART DBP-CART-125SOL145	272	RC	C1724	CPT				Both			7500	3375	525.82	6750	525.82							Fee Schedule		5550							Fee Schedule																													6750							Fee Schedule																																															
CSI DIAMONDBACK CART DBP-CART-150SOL145	272	RC	C1724	CPT				Both			7500	3375	525.82	6750	525.82							Fee Schedule		5550							Fee Schedule																													6750							Fee Schedule																																															
CSI DIAMONDBACK CART DBP-CART-200CLA145	272	RC	C1724	CPT				Both			7500	3375	525.82	6750	525.82							Fee Schedule		5550							Fee Schedule																													6750							Fee Schedule																																															
CSI DIAMONDBACK CART DBP-CART-200SOL145	272	RC	C1724	CPT				Both			7500	3375	525.82	6750	525.82							Fee Schedule		5550							Fee Schedule																													6750							Fee Schedule																																															
CSI DIAMONDBACK EXC 125 DBP-EX-125MIC145	272	RC	C1724	CPT				Both			11685	5258.25	525.82	10516.5	525.82							Fee Schedule		8646.9							Fee Schedule																													10516.5							Fee Schedule																																															
CSI DIAMONDBACK EXC 125 DBP-EX-125SOL145	272	RC	C1724	CPT				Both			11685	5258.25	525.82	10516.5	525.82							Fee Schedule		8646.9							Fee Schedule																													10516.5							Fee Schedule																																															
CSI DIAMONDBACK EXC 150 DBP-EX-150CLA145	272	RC	C1724	CPT				Both			11085	4988.25	525.82	9976.5	525.82							Fee Schedule		8202.9							Fee Schedule																													9976.5							Fee Schedule																																															
CSI DIAMONDBACK EXC 200 DBP-EX-200CLA145	272	RC	C1724	CPT				Both			11085	4988.25	525.82	9976.5	525.82							Fee Schedule		8202.9							Fee Schedule																													9976.5							Fee Schedule																																															
CSI DIAMONDBACK EXC 200 DBP-EX-200SOL145	272	RC	C1724	CPT				Both			11085	4988.25	525.82	9976.5	525.82							Fee Schedule		8202.9							Fee Schedule																													9976.5							Fee Schedule																																															
CSI DIAMONDBACK EXC 360 DBP-EX-150SOL145	272	RC	C1724	CPT				Both			11085	4988.25	525.82	9976.5	525.82							Fee Schedule		8202.9							Fee Schedule																													9976.5							Fee Schedule																																															
CSI PTA CATHETER 5.0 585012032	272	RC	C1725	CPT				Both			825	371.25	93.3	742.5	93.3							Fee Schedule		610.5							Fee Schedule																													742.5							Fee Schedule																																															
CSI PTA CATHETER 584024022	272	RC	C1725	CPT				Both			675	303.75	93.3	607.5	93.3							Fee Schedule		499.5							Fee Schedule																													607.5							Fee Schedule																																															
CT  ABD W CONTRAST 3D	352	RC	74160	CPT				Both			2100	945	159.3	2478	956							Per Diem		159.3							Fee Schedule											193.78							Fee Schedule											1890							Fee Schedule																				2478							Case Rate																				
CT  ABD WWO CONTRAST 3D	350	RC	74170	CPT				Both			2100	945	143.07	2478	956							Per Diem		182.68							Fee Schedule		158.46							Fee Schedule		240.46							Fee Schedule		153.84							Fee Schedule		1890							Fee Schedule		176.92							Fee Schedule		143.07							Fee Schedule		2478							Case Rate		176.92							Fee Schedule		143.07							Fee Schedule		
CT 3D MPR IND WKSTN	350	RC	76377	CPT				Both			2100	945	28.44	2478	956							Per Diem		28.44							Fee Schedule											98.85							Fee Schedule											1890							Fee Schedule																				2478							Case Rate																				
CT 3D MPR-MODIFIER	352	RC	76376	CPT				Both			720.3	324.14	11.88	2478	220							Fee Schedule	Not Reimbursed	11.88							Fee Schedule											94.38							Fee Schedule											648.27							Fee Schedule																				2478							Case Rate																				
CT ABD WO CONTRAST 3D	352	RC	74150	CPT				Both			2100	945	81.69	2478	956							Per Diem		81.69							Fee Schedule											160.16							Fee Schedule											1890							Fee Schedule																				2478							Case Rate																				
CT ABD/PEL WO CONTRAST 3D	352	RC	74176	CPT				Both			2100	945	101.11	2478	956							Per Diem		102.8							Fee Schedule											101.11							Fee Schedule											1890							Fee Schedule																				2478							Case Rate																				
CT ABD/PEL WWO CONTRAST 3D	350	RC	74178	CPT				Both			2100	945	236.77	2478	956							Per Diem		236.77							Fee Schedule											255.01							Fee Schedule											1890							Fee Schedule																				2478							Case Rate																				
CT ABD/PELVIS W CONTRAST 3D	352	RC	74177	CPT				Both			2100	945	192.93	2478	956							Per Diem		207.36							Fee Schedule											192.93							Fee Schedule											1890							Fee Schedule																				2478							Case Rate																				
CT ACCUSTK II KIT NITINOL	272	RC						Both			262.5	118.13	118.13	236.25	170.63							Fee Schedule		194.25							Fee Schedule																													236.25							Fee Schedule																																															
CT BONE DENSITY MONITORING	350	RC	77078	CPT				Both			2100	945	93.39	2478	956							Per Diem		93.71							Fee Schedule											93.39							Fee Schedule											1890							Fee Schedule																				2478							Case Rate																				
CT BONE DENSITY SCREENING	350	RC	77078	CPT				Both			2100	945	93.39	2478	956							Per Diem		93.71							Fee Schedule											93.39							Fee Schedule											1890							Fee Schedule																				2478							Case Rate																				
CT CALCIUM SCORING	359	RC	75571	CPT				Both			420	189	44.48	2478	220							Fee Schedule	Not Reimbursed	68.05							Fee Schedule											44.48							Fee Schedule											378							Fee Schedule																				2478							Case Rate																				
CT CATH CUFF KIT	272	RC						Both			49.35	22.21	22.21	44.42	32.08							Fee Schedule		36.52							Fee Schedule																													44.42							Fee Schedule																																															
CT CERVICAL W&WO CONTRAST 3D	350	RC	72127	CPT				Both			2100	945	187.55	2478	956							Per Diem		187.55							Fee Schedule											250.31							Fee Schedule											1890							Fee Schedule																				2478							Case Rate																				
CT CERVICAL WO CONTRAST 3D	350	RC	72125	CPT				Both			2100	945	118.71	2478	956							Per Diem		118.71							Fee Schedule											167.06							Fee Schedule											1890							Fee Schedule																				2478							Case Rate																				
CT CHEST ABDOMEN W CONTRAST 3D	350	RC	71260	CPT				Both			2100	945	121.96	2478	956							Per Diem		121.96							Fee Schedule											200.25							Fee Schedule											1890							Fee Schedule																				2478							Case Rate																				
CT CHEST ABDOMEN WO CONTRAST 3D	350	RC	74150	CPT				Both			2100	945	81.69	2478	956							Per Diem		81.69							Fee Schedule											160.16							Fee Schedule											1890							Fee Schedule																				2478							Case Rate																				
CT CHEST ABDOMEN WWO CONTRAST 3D	350	RC	71270	CPT				Both			2100	945	148.91	2478	956							Per Diem		148.91							Fee Schedule											250.31							Fee Schedule											1890							Fee Schedule																				2478							Case Rate																				
CT CHEST W CONTRAST 3D	350	RC	71260	CPT				Both			2100	945	121.96	2478	956							Per Diem		121.96							Fee Schedule											200.25							Fee Schedule											1890							Fee Schedule																				2478							Case Rate																				
CT CHEST WO CONTRAST 3D	350	RC	71250	CPT				Both			2100	945	91.11	2478	956							Per Diem		91.11							Fee Schedule											167.06							Fee Schedule											1890							Fee Schedule																				2478							Case Rate																				
CT CHEST WWO CONTRAST 3D	350	RC	71270	CPT				Both			2100	945	148.91	2478	956							Per Diem		148.91							Fee Schedule											250.31							Fee Schedule											1890							Fee Schedule																				2478							Case Rate																				
CT CHEST/ABD/PEL W CONTRAST 3D	350	RC	71260	CPT				Both			2100	945	121.96	2478	956							Per Diem		121.96							Fee Schedule											200.25							Fee Schedule											1890							Fee Schedule																				2478							Case Rate																				
CT CHEST/ABD/PEL WO CONTRAST 3D	352	RC	71250	CPT				Both			2100	945	91.11	2478	956							Per Diem		91.11							Fee Schedule											167.06							Fee Schedule											1890							Fee Schedule																				2478							Case Rate																				
CT CHEST/ABD/PELVIS WWO CONTRAST 3D	350	RC	71270	CPT				Both			2100	945	148.91	2478	956							Per Diem		148.91							Fee Schedule											250.31							Fee Schedule											1890							Fee Schedule																				2478							Case Rate																				
CT CNNCTING TUBE (C TBE-2)	272	RC						Both			43.05	19.37	19.37	38.75	27.98							Fee Schedule		31.86							Fee Schedule																													38.75							Fee Schedule																																															
CT DILATOR 10FR (VCD/12/25)	272	RC						Both			234.15	105.37	105.37	210.74	152.2							Fee Schedule		173.27							Fee Schedule																													210.74							Fee Schedule																																															
CT FACIAL BONES WO CONTRAST 3D	351	RC	70486	CPT				Both			2100	945	87.54	2478	956							Per Diem		87.54							Fee Schedule											133.73							Fee Schedule											1890							Fee Schedule																				2478							Case Rate																				
CT FACIAL BONES WWO CONTRAST 3D	351	RC	70488	CPT				Both			2100	945	127.48	2478	956							Per Diem		127.48							Fee Schedule											200.25							Fee Schedule											1890							Fee Schedule																				2478							Case Rate																				
CT FLEX APDL 10 FR REG KIT	272	RC						Both			493.5	222.08	222.08	444.15	320.78							Fee Schedule		365.19							Fee Schedule																													444.15							Fee Schedule																																															
CT FLEXIMA APDL 12F/25CM	272	RC						Both			265.65	119.54	119.54	239.09	172.67							Fee Schedule		196.58							Fee Schedule																													239.09							Fee Schedule																																															
CT FLEXIMA APDL 14F/25CM	272	RC						Both			265.65	119.54	119.54	239.09	172.67							Fee Schedule		196.58							Fee Schedule																													239.09							Fee Schedule																																															
CT FLEXIMA APDL 14F/25CM	272	RC						Both			317.1	142.7	142.7	285.39	206.12							Fee Schedule		234.65							Fee Schedule																													285.39							Fee Schedule																																															
CT GUIDED ABS DRAIN	320	RC	75989	CPT				Both			315	141.75	57.34	318	220							Fee Schedule		57.34							Fee Schedule											89.02							Fee Schedule											283.5							Fee Schedule																				318							Per Diem																				
CT GUIDED NEEDLE BIOPSY	359	RC	77012	CPT				Both			2100	945	70.33	2478	956							Per Diem		70.33							Fee Schedule											188.41							Fee Schedule											1890							Fee Schedule																				2478							Case Rate																				
CT HEAD W CONTRAST 3D	351	RC	70460	CPT				Both			2100	945	96.95	2478	956							Per Diem		96.95							Fee Schedule											160.16							Fee Schedule											1890							Fee Schedule																				2478							Case Rate																				
CT HEAD WO (STROKE PROTOCOL) 3D	351	RC	70450	CPT				Both			2100	945	66.43	2478	956							Per Diem		66.43							Fee Schedule											133.73							Fee Schedule											1890							Fee Schedule																				2478							Case Rate																				
CT HEAD WO CONTRAST 3D	351	RC	70450	CPT				Both			2100	945	66.43	2478	956							Per Diem		66.43							Fee Schedule											133.73							Fee Schedule											1890							Fee Schedule																				2478							Case Rate																				
CT HEAD WWO CONTRAST 3D	351	RC	70470	CPT				Both			2100	945	116.11	2478	956							Per Diem		116.11							Fee Schedule											200.25							Fee Schedule											1890							Fee Schedule																				2478							Case Rate																				
CT HEART MORPHOLOGY	359	RC	75572	CPT				Both			2100	945	128.41	2478	956							Per Diem		163.71							Fee Schedule											128.41							Fee Schedule											1890							Fee Schedule																				2478							Case Rate																				
CT LOWER EXTREMITY LT WITH 3D	350	RC	73701	CPT				Both			2100	945	152.48	2478	956							Per Diem		152.48							Fee Schedule											167.06							Fee Schedule											1890							Fee Schedule																				2478							Case Rate																				
CT LOWER EXTREMITY LT WO 3D	350	RC	73700	CPT				Both			2100	945	117.74	2478	956							Per Diem		117.74							Fee Schedule											140.34							Fee Schedule											1890							Fee Schedule																				2478							Case Rate																				
CT LOWER EXTREMITY LT WWO 3D	350	RC	73702	CPT				Both			2100	945	193.72	2478	956							Per Diem		193.72							Fee Schedule											210.35							Fee Schedule											1890							Fee Schedule																				2478							Case Rate																				
CT LOWER EXTREMITY RT WITH 3D	350	RC	73701	CPT				Both			2100	945	152.48	2478	956							Per Diem		152.48							Fee Schedule											167.06							Fee Schedule											1890							Fee Schedule																				2478							Case Rate																				
CT LOWER EXTREMITY RT WO 3D	350	RC	73700	CPT				Both			2100	945	117.74	2478	956							Per Diem		117.74							Fee Schedule											140.34							Fee Schedule											1890							Fee Schedule																				2478							Case Rate																				
CT LOWER EXTREMITY RT WWO 3D	350	RC	73702	CPT				Both			2100	945	193.72	2478	956							Per Diem		193.72							Fee Schedule											210.35							Fee Schedule											1890							Fee Schedule																				2478							Case Rate																				
CT LUMBAR SPINE W CONTRAST 3D	350	RC	72132	CPT				Both			2100	945	151.51	2478	956							Per Diem		151.51							Fee Schedule											200.25							Fee Schedule											1890							Fee Schedule																				2478							Case Rate																				
CT LUMBAR WO CONTRAST 3D	350	RC	72131	CPT				Both			2100	945	117.74	2478	956							Per Diem		117.74							Fee Schedule											167.06							Fee Schedule											1890							Fee Schedule																				2478							Case Rate																				
CT NECK W CONTRAST 3D	350	RC	70491	CPT				Both			2100	945	121.31	2478	956							Per Diem		121.31							Fee Schedule											160.16							Fee Schedule											1890							Fee Schedule																				2478							Case Rate																				
CT NECK WO CONTRAST 3D	350	RC	70490	CPT				Both			2100	945	91.11	2478	956							Per Diem		91.11							Fee Schedule											133.73							Fee Schedule											1890							Fee Schedule																				2478							Case Rate																				
CT NECK WWO CONTRAST 3D	350	RC	70492	CPT				Both			2100	945	148.58	2478	956							Per Diem		148.58							Fee Schedule											200.25							Fee Schedule											1890							Fee Schedule																				2478							Case Rate																				
CT ORB/SEL/IAC WO CONTRAST 3D	351	RC	70480	CPT				Both			2100	945	133.73	2478	956							Per Diem		153.45							Fee Schedule											133.73							Fee Schedule											1890							Fee Schedule																				2478							Case Rate																				
CT ORB/SEL/IAC WWO CONTRAST 3D	351	RC	70482	CPT				Both			2100	945	200.25	2478	956							Per Diem		207.22							Fee Schedule											200.25							Fee Schedule											1890							Fee Schedule																				2478							Case Rate																				
CT PELVIS ASSOCIATED CHARGE 3D	352	RC	72193	CPT				Both			2100	945	159.95	2478	956							Per Diem		159.95							Fee Schedule											193.78							Fee Schedule											1890							Fee Schedule																				2478							Case Rate																				
CT PELVIS W CONTRAST 3D	352	RC	72193	CPT				Both			2100	945	159.95	2478	956							Per Diem		159.95							Fee Schedule											193.78							Fee Schedule											1890							Fee Schedule																				2478							Case Rate																				
CT PELVIS WO CONTRAST 3D	352	RC	72192	CPT				Both			2100	945	82.67	2478	956							Per Diem		82.67							Fee Schedule											167.06							Fee Schedule											1890							Fee Schedule																				2478							Case Rate																				
CT PELVIS WWO CONTRAST 3D	352	RC	72194	CPT				Both			2100	945	143.07	2478	956							Per Diem		186.57							Fee Schedule		158.46							Fee Schedule		240.46							Fee Schedule		153.84							Fee Schedule		1890							Fee Schedule		176.92							Fee Schedule		143.07							Fee Schedule		2478							Case Rate		176.92							Fee Schedule		143.07							Fee Schedule		
CT SCANNER COVER #107.0017 EDM MEDICAL	272	RC						Both			33	14.85	14.85	29.7	21.45							Fee Schedule		24.42							Fee Schedule																													29.7							Fee Schedule																																															
CT SINUS WO CONTRAST 3D	351	RC	70486	CPT				Both			2100	945	87.54	2478	956							Per Diem		87.54							Fee Schedule											133.73							Fee Schedule											1890							Fee Schedule																				2478							Case Rate																				
CT SINUS WWO CONTRAST 3D	351	RC	70488	CPT				Both			2100	945	127.48	2478	956							Per Diem		127.48							Fee Schedule											200.25							Fee Schedule											1890							Fee Schedule																				2478							Case Rate																				
CT THORACIC SPINE WO CONTRAST 3D	350	RC	72128	CPT				Both			2100	945	118.38	2478	956							Per Diem		118.38							Fee Schedule											167.06							Fee Schedule											1890							Fee Schedule																				2478							Case Rate																				
CT UPPER EXTREMITY LT W 3D	350	RC	73201	CPT				Both			2100	945	149.88	2478	956							Per Diem		149.88							Fee Schedule											167.06							Fee Schedule											1890							Fee Schedule																				2478							Case Rate																				
CT UPPER EXTREMITY LT WO 3D	350	RC	73200	CPT				Both			2100	945	85.17	2478	956							Per Diem		117.41							Fee Schedule		94.33							Fee Schedule		140.34							Fee Schedule		91.58							Fee Schedule		1890							Fee Schedule		105.32							Fee Schedule		85.17							Fee Schedule		2478							Case Rate		105.32							Fee Schedule		85.17							Fee Schedule		
CT UPPER EXTREMITY LT WWO 3D	350	RC	73201	CPT				Both			2100	945	149.88	2478	956							Per Diem		149.88							Fee Schedule											167.06							Fee Schedule											1890							Fee Schedule																				2478							Case Rate																				
CT UPPER EXTREMITY RT W 3D	350	RC	73201	CPT				Both			2100	945	149.88	2478	956							Per Diem		149.88							Fee Schedule											167.06							Fee Schedule											1890							Fee Schedule																				2478							Case Rate																				
CT UPPER EXTREMITY RT WO 3D	350	RC	73200	CPT				Both			2100	945	85.17	2478	956							Per Diem		117.41							Fee Schedule		94.33							Fee Schedule		140.34							Fee Schedule		91.58							Fee Schedule		1890							Fee Schedule		105.32							Fee Schedule		85.17							Fee Schedule		2478							Case Rate		105.32							Fee Schedule		85.17							Fee Schedule		
CT UPPER EXTREMITY RT WWO 3D	350	RC	73201	CPT				Both			2100	945	149.88	2478	956							Per Diem		149.88							Fee Schedule											167.06							Fee Schedule											1890							Fee Schedule																				2478							Case Rate																				
CTA  ADD ON EACH ADDITIONAL VESSEL	359	RC	75574	CPT				Both			2100	945	248.97	2478	956							Per Diem		248.97							Fee Schedule											335.08							Fee Schedule											1890							Fee Schedule																				2478							Case Rate																				
CTA ABDOMEN	350	RC	74175	CPT				Both			2100	945	142.81	2478	956							Per Diem		204.3							Fee Schedule		158.17							Fee Schedule		241.52							Fee Schedule		153.56							Fee Schedule		1890							Fee Schedule		176.59							Fee Schedule		142.81							Fee Schedule		2478							Case Rate		176.59							Fee Schedule		142.81							Fee Schedule		
CTA ABDOMEN PELVIS	352	RC	74174	CPT				Both			2100	945	261.45	2478	956							Per Diem		261.45							Fee Schedule											333.14							Fee Schedule											1890							Fee Schedule																				2478							Case Rate																				
CTA AORTA RUNOFF	350	RC	75635	CPT				Both			2100	945	142.97	2478	956							Per Diem		294.43							Fee Schedule		158.34							Fee Schedule		241.52							Fee Schedule		153.73							Fee Schedule		1890							Fee Schedule		176.79							Fee Schedule		142.97							Fee Schedule		2478							Case Rate		176.79							Fee Schedule		142.97							Fee Schedule		
CTA CHEST	350	RC	71275	CPT				Both			2100	945	142.97	2478	956							Per Diem		191.63							Fee Schedule		158.34							Fee Schedule		251.3							Fee Schedule		153.73							Fee Schedule		1890							Fee Schedule		176.79							Fee Schedule		142.97							Fee Schedule		2478							Case Rate		176.79							Fee Schedule		142.97							Fee Schedule		
CTA CHEST CT ABD/PELVIS WITH CONTRAST	350	RC	71275	CPT				Both			2100	945	142.97	2478	956							Per Diem		191.63							Fee Schedule		158.34							Fee Schedule		251.3							Fee Schedule		153.73							Fee Schedule		1890							Fee Schedule		176.79							Fee Schedule		142.97							Fee Schedule		2478							Case Rate		176.79							Fee Schedule		142.97							Fee Schedule		
CTA HEAD BRAIN	351	RC	70496	CPT				Both			2100	945	142.97	2478	956							Per Diem		188.71							Fee Schedule		158.34							Fee Schedule		204.63							Fee Schedule		153.73							Fee Schedule		1890							Fee Schedule		176.79							Fee Schedule		142.97							Fee Schedule		2478							Case Rate		176.79							Fee Schedule		142.97							Fee Schedule		
CTA HEAD/CTA NECK	351	RC	70471	CPT				Both			2100	945	190.61	2478	956							Per Diem		234.62							Fee Schedule											190.61							Fee Schedule											1890							Fee Schedule																				2478							Case Rate																				
CTA LOWER EXTREMITY LEFT	350	RC	73706	CPT				Both			2100	945	142.7	2478	956							Per Diem		237.61							Fee Schedule		158.04							Fee Schedule		211.85							Fee Schedule		153.44							Fee Schedule		1890							Fee Schedule		176.46							Fee Schedule		142.7							Fee Schedule		2478							Case Rate		176.46							Fee Schedule		142.7							Fee Schedule		
CTA LOWER EXTREMITY RIGHT	350	RC	73706	CPT				Both			2100	945	142.7	2478	956							Per Diem		237.61							Fee Schedule		158.04							Fee Schedule		211.85							Fee Schedule		153.44							Fee Schedule		1890							Fee Schedule		176.46							Fee Schedule		142.7							Fee Schedule		2478							Case Rate		176.46							Fee Schedule		142.7							Fee Schedule		
CTA NECK CAROTID	351	RC	70498	CPT				Both			2100	945	142.97	2478	956							Per Diem		188.06							Fee Schedule		158.34							Fee Schedule		204.63							Fee Schedule		153.73							Fee Schedule		1890							Fee Schedule		176.79							Fee Schedule		142.97							Fee Schedule		2478							Case Rate		176.79							Fee Schedule		142.97							Fee Schedule		
CTA PELVIS	350	RC	72191	CPT				Both			2100	945	142.81	2478	956							Per Diem		203.97							Fee Schedule		158.17							Fee Schedule		241.52							Fee Schedule		153.56							Fee Schedule		1890							Fee Schedule		176.59							Fee Schedule		142.81							Fee Schedule		2478							Case Rate		176.59							Fee Schedule		142.81							Fee Schedule		
CTA UPPER EXTREMITY LEFT	350	RC	73206	CPT				Both			2100	945	142.97	2478	956							Per Diem		216.96							Fee Schedule		158.34							Fee Schedule		211.85							Fee Schedule		153.73							Fee Schedule		1890							Fee Schedule		176.79							Fee Schedule		142.97							Fee Schedule		2478							Case Rate		176.79							Fee Schedule		142.97							Fee Schedule		
CTA UPPER EXTREMITY RIGHT	350	RC	73206	CPT				Both			2100	945	142.97	2478	956							Per Diem		216.96							Fee Schedule		158.34							Fee Schedule		211.85							Fee Schedule		153.73							Fee Schedule		1890							Fee Schedule		176.79							Fee Schedule		142.97							Fee Schedule		2478							Case Rate		176.79							Fee Schedule		142.97							Fee Schedule		
CTTNG ELECTR 83A2203	272	RC						Both			205.8	92.61	92.61	185.22	133.77							Fee Schedule		152.29							Fee Schedule																													185.22							Fee Schedule																																															
CTTNG ELECTRDS A2189	272	RC						Both			182.7	82.22	82.22	164.43	118.76							Fee Schedule		135.2							Fee Schedule																													164.43							Fee Schedule																																															
CTTNG ELECTRDS A2196	272	RC						Both			266.7	120.02	120.02	240.03	173.36							Fee Schedule		197.36							Fee Schedule																													240.03							Fee Schedule																																															
CUBE PESSARY	272	RC						Both			111.3	50.09	50.09	100.17	72.35							Fee Schedule		82.36							Fee Schedule																													100.17							Fee Schedule																																															
CUDDLES YELLOW SECURITY BANDS 100908	270	RC						Both			17	7.65	7.65	15.3	11.05							Fee Schedule		12.58							Fee Schedule																													15.3							Fee Schedule																																															
CULTURE AFB CONCLUS 4554 SPUTUM	306	RC	87118	CPT				Both			63	28.35	10.52	56.7	10.52							Fee Schedule		14.61							Fee Schedule		15.05							Fee Schedule		14.61							Fee Schedule		14.61							Fee Schedule		56.7							Fee Schedule		16.8							Fee Schedule		13.59							Fee Schedule		14.61							Fee Schedule		16.8							Fee Schedule		13.59							Fee Schedule		
CULTURE AFB TO STATE LAB ONLY SPUTUM	306	RC	87118	CPT				Both			63	28.35	10.52	56.7	10.52							Fee Schedule		14.61							Fee Schedule		15.05							Fee Schedule		14.61							Fee Schedule		14.61							Fee Schedule		56.7							Fee Schedule		16.8							Fee Schedule		13.59							Fee Schedule		14.61							Fee Schedule		16.8							Fee Schedule		13.59							Fee Schedule		
CULTURE BLOOD	306	RC	87040	CPT				Both			97.65	43.94	9.17	87.89	9.17							Fee Schedule		11.47							Fee Schedule		10.63							Fee Schedule		10.32							Fee Schedule		10.32							Fee Schedule		87.89							Fee Schedule		11.87							Fee Schedule		9.6							Fee Schedule		10.32							Fee Schedule		11.87							Fee Schedule		9.6							Fee Schedule		
CULTURE BLOOD QUEST 389	306	RC	87040	CPT				Both			97.65	43.94	9.17	87.89	9.17							Fee Schedule		11.47							Fee Schedule		10.63							Fee Schedule		10.32							Fee Schedule		10.32							Fee Schedule		87.89							Fee Schedule		11.87							Fee Schedule		9.6							Fee Schedule		10.32							Fee Schedule		11.87							Fee Schedule		9.6							Fee Schedule		
CULTURE CHLAMYDIA 690	306	RC	87110	CPT				Both			110.25	49.61	17.42	99.23	17.42							Fee Schedule		21.77							Fee Schedule		20.19							Fee Schedule		19.6							Fee Schedule		19.6							Fee Schedule		99.23							Fee Schedule		22.54							Fee Schedule		18.23							Fee Schedule		19.6							Fee Schedule		22.54							Fee Schedule		18.23							Fee Schedule		
CULTURE FUNGI EACH MOLD	306	RC	87107	CPT				Both			47.25	21.26	9.17	42.53	9.17							Fee Schedule		11.47							Fee Schedule		10.63							Fee Schedule		10.32							Fee Schedule		10.32							Fee Schedule		42.53							Fee Schedule		11.87							Fee Schedule		9.6							Fee Schedule		10.32							Fee Schedule		11.87							Fee Schedule		9.6							Fee Schedule		
CULTURE FUNGI EACH MOLD	306	RC	87107	CPT				Both			47.25	21.26	9.17	42.53	9.17							Fee Schedule		11.47							Fee Schedule		10.63							Fee Schedule		10.32							Fee Schedule		10.32							Fee Schedule		42.53							Fee Schedule		11.87							Fee Schedule		9.6							Fee Schedule		10.32							Fee Schedule		11.87							Fee Schedule		9.6							Fee Schedule		
CULTURE FUNGI EACH YEAST	306	RC	87106	CPT				Both			47.25	21.26	9.17	42.53	9.17							Fee Schedule		11.47							Fee Schedule		10.63							Fee Schedule		10.32							Fee Schedule		10.32							Fee Schedule		42.53							Fee Schedule		11.87							Fee Schedule		9.6							Fee Schedule		10.32							Fee Schedule		11.87							Fee Schedule		9.6							Fee Schedule		
CULTURE FUNGUS	306	RC	87102	CPT				Both			68.25	30.71	7.47	61.43	7.47							Fee Schedule		9.34							Fee Schedule		8.66							Fee Schedule		8.41							Fee Schedule		8.41							Fee Schedule		61.43							Fee Schedule		9.67							Fee Schedule		7.82							Fee Schedule		8.41							Fee Schedule		9.67							Fee Schedule		7.82							Fee Schedule		
CULTURE FUNGUS SPUTUM	306	RC	87102	CPT				Both			68.25	30.71	7.47	61.43	7.47							Fee Schedule		9.34							Fee Schedule		8.66							Fee Schedule		8.41							Fee Schedule		8.41							Fee Schedule		61.43							Fee Schedule		9.67							Fee Schedule		7.82							Fee Schedule		8.41							Fee Schedule		9.67							Fee Schedule		7.82							Fee Schedule		
CULTURE GC	300	RC	87070	CPT				Both			47.25	21.26	7.66	42.53	7.66							Fee Schedule		9.57							Fee Schedule		8.88							Fee Schedule		8.62							Fee Schedule		8.62							Fee Schedule		42.53							Fee Schedule		9.91							Fee Schedule		8.02							Fee Schedule		8.62							Fee Schedule		9.91							Fee Schedule		8.02							Fee Schedule		
CULTURE MYCOPLASMA HOMINIS 871	306	RC	87109	CPT				Both			48	21.6	13.68	43.2	13.68							Fee Schedule		17.1							Fee Schedule		15.85							Fee Schedule		15.39							Fee Schedule		15.39							Fee Schedule		43.2							Fee Schedule		17.7							Fee Schedule		14.31							Fee Schedule		15.39							Fee Schedule		17.7							Fee Schedule		14.31							Fee Schedule		
CULTURE OTHER SOURCE	306	RC	87070	CPT				Both			161	72.45	7.66	144.9	7.66							Fee Schedule		9.57							Fee Schedule		8.88							Fee Schedule		8.62							Fee Schedule		8.62							Fee Schedule		144.9							Fee Schedule		9.91							Fee Schedule		8.02							Fee Schedule		8.62							Fee Schedule		9.91							Fee Schedule		8.02							Fee Schedule		
CULTURE SPUTUM	306	RC	87070	CPT				Both			71.4	32.13	7.66	64.26	7.66							Fee Schedule		9.57							Fee Schedule		8.88							Fee Schedule		8.62							Fee Schedule		8.62							Fee Schedule		64.26							Fee Schedule		9.91							Fee Schedule		8.02							Fee Schedule		8.62							Fee Schedule		9.91							Fee Schedule		8.02							Fee Schedule		
CULTURE STOOL	300	RC	87045	CPT				Both			65.1	29.3	8.4	58.59	8.4							Fee Schedule		10.49							Fee Schedule		9.72							Fee Schedule		9.44							Fee Schedule		9.44							Fee Schedule		58.59							Fee Schedule		10.86							Fee Schedule		8.78							Fee Schedule		9.44							Fee Schedule		10.86							Fee Schedule		8.78							Fee Schedule		
CULTURE TB AFB SPUTUM 4554	306	RC	87116	CPT				Both			73.5	33.08	9.6	66.15	9.6							Fee Schedule		12							Fee Schedule		11.12							Fee Schedule		10.8							Fee Schedule		10.8							Fee Schedule		66.15							Fee Schedule		12.42							Fee Schedule		10.04							Fee Schedule		10.8							Fee Schedule		12.42							Fee Schedule		10.04							Fee Schedule		
CULTURE URINE	300	RC	87086	CPT				Both			100.8	45.36	7.17	90.72	7.17							Fee Schedule		8.97							Fee Schedule		8.31							Fee Schedule		8.07							Fee Schedule		8.07							Fee Schedule		90.72							Fee Schedule		9.28							Fee Schedule		7.51							Fee Schedule		8.07							Fee Schedule		9.28							Fee Schedule		7.51							Fee Schedule		
CULTURE YERSINIA STOOL 4487	306	RC	87046	CPT				Both			66.15	29.77	8.4	59.54	8.4							Fee Schedule		10.49							Fee Schedule		9.72							Fee Schedule		9.44							Fee Schedule		9.44							Fee Schedule		59.54							Fee Schedule		10.86							Fee Schedule		8.78							Fee Schedule		9.44							Fee Schedule		10.86							Fee Schedule		8.78							Fee Schedule		
CURAD XEROFORM DRESSING 1X8 CUR253180WZ	272	RC	A6222	CPT				Both			2	0.9	0.9	3.5	1.92							Fee Schedule		1.48							Fee Schedule		3.13							Fee Schedule		2.4							Fee Schedule		3.04							Fee Schedule		1.8							Fee Schedule		3.5							Fee Schedule		2.83							Fee Schedule											3.5							Fee Schedule		2.83							Fee Schedule		
CURASOL GEL WOUND DRESSING-90GM TUBE	250	RC						Both			45.15	20.32	20.32	40.64	29.35							Fee Schedule		33.41							Fee Schedule																													40.64							Fee Schedule																																															
CUREL LOTION	250	RC	A9270	CPT				Both			7.35	3.31	0.01	6.62	0.01							Fee Schedule		5.44							Fee Schedule																													6.62							Fee Schedule																																															
CURETTE DERMAL 3MM 33-53	272	RC						Both			8	3.6	3.6	7.2	5.2							Fee Schedule		5.92							Fee Schedule																													7.2							Fee Schedule																																															
CURETTE DERMAL 4MM 33-54	272	RC						Both			8	3.6	3.6	7.2	5.2							Fee Schedule		5.92							Fee Schedule																													7.2							Fee Schedule																																															
CURETTE DERMAL 5MM 33-55	272	RC						Both			9	4.05	4.05	8.1	5.85							Fee Schedule		6.66							Fee Schedule																													8.1							Fee Schedule																																															
CURETTE DERMAL 7MM 33-57	272	RC						Both			9	4.05	4.05	8.1	5.85							Fee Schedule		6.66							Fee Schedule																													8.1							Fee Schedule																																															
CURETTES 14MM 21593	272	RC						Both			16.8	7.56	7.56	15.12	10.92							Fee Schedule		12.43							Fee Schedule																													15.12							Fee Schedule																																															
CUSHION METATARSAL LG #8188L	270	RC	L3050	CPT				Both			20	9	9	66.87	23.42							Fee Schedule		14.8							Fee Schedule		59.89							Fee Schedule		45.93							Fee Schedule		58.15							Fee Schedule		18							Fee Schedule		66.87							Fee Schedule		54.08							Fee Schedule											66.87							Fee Schedule		54.08							Fee Schedule		
CUSHION RING (DONUT) #513-8016-2400	271	RC	E0190	CPT				Both			46	20.7	20.7	41.4	35.61							Fee Schedule		34.04							Fee Schedule																													41.4							Fee Schedule																																															
CUTIMED SOIBACT WOUND DRESSING 72661201	272	RC	A6212	CPT				Both			11	4.95	4.95	15.92	8.74							Fee Schedule		8.14							Fee Schedule		14.26							Fee Schedule		10.93							Fee Schedule		13.84							Fee Schedule		9.9							Fee Schedule		15.92							Fee Schedule		12.87							Fee Schedule											15.92							Fee Schedule		12.87							Fee Schedule		
CUTTER 5MM FULL RADIUS	272	RC						Both			226.8	102.06	102.06	204.12	147.42							Fee Schedule		167.83							Fee Schedule																													204.12							Fee Schedule																																															
CUTTING LOOP	272	RC						Both			165.9	74.66	74.66	149.31	107.84							Fee Schedule		122.77							Fee Schedule																													149.31							Fee Schedule																																															
CUTTING LOOP ELECTRODE #4812T-012	272	RC						Both			341.25	153.56	153.56	307.13	221.81							Fee Schedule		252.53							Fee Schedule																													307.13							Fee Schedule																																															
CVAC ASPIRATION  DEVICE # CVC127020-1	272	RC	C9761	CPT				Both			10485	4718.25	4718.25	11122.23	6815.25							Fee Schedule		7758.9							Fee Schedule		9961.65							Fee Schedule											9671.5							Fee Schedule		9436.5							Fee Schedule		11122.23							Fee Schedule		8994.5							Fee Schedule											11122.23							Fee Schedule		8994.5							Fee Schedule		
CYANIDE ANTIDOTE KIT (NITHIODOTE)	250	RC	J0211	CPT				Both			865.2	389.34	1.98	778.68	562.38							Fee Schedule		1.98							Fee Schedule		2.23							Fee Schedule											2.17							Fee Schedule		778.68							Fee Schedule		2.49							Fee Schedule		2.01							Fee Schedule											2.49							Fee Schedule		2.01							Fee Schedule		
CYANIDE BLOOD 400 GRAY TOP TUBE	301	RC	82600	CPT				Both			105	47.25	17.24	94.5	17.24							Fee Schedule		21.55							Fee Schedule		19.98							Fee Schedule		19.4							Fee Schedule		19.4							Fee Schedule		94.5							Fee Schedule		22.31							Fee Schedule		18.04							Fee Schedule		19.4							Fee Schedule		22.31							Fee Schedule		18.04							Fee Schedule		
CYANOCOBALAMIN 1000 MCG/ML INJ-1ML	636	RC	J3420	CPT				Both			27.3	12.29	0.3	24.57		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	20.2							Fee Schedule		0.7							Fee Schedule		0.3							Fee Schedule		0.68							Fee Schedule		24.57							Fee Schedule		0.79							Fee Schedule		0.64							Fee Schedule											0.79							Fee Schedule		0.64							Fee Schedule		
CYCLIC CITRULLIN PEPTIDE 11173 1ML SERUM	301	RC	83520	CPT				Both			158.55	71.35	12.43	142.7	12.43							Fee Schedule		17.27							Fee Schedule		17.79							Fee Schedule		17.27							Fee Schedule		17.27							Fee Schedule		142.7							Fee Schedule		19.86							Fee Schedule		16.06							Fee Schedule		17.27							Fee Schedule		19.86							Fee Schedule		16.06							Fee Schedule		
CYCLIC CITRULLINAED PEPTIDE 11173 1ML SE	302	RC	86200	CPT				Both			147	66.15	11.51	132.3	11.51							Fee Schedule		14.39							Fee Schedule		13.34							Fee Schedule		12.95							Fee Schedule		12.95							Fee Schedule		132.3							Fee Schedule		14.89							Fee Schedule		12.04							Fee Schedule		12.95							Fee Schedule		14.89							Fee Schedule		12.04							Fee Schedule		
CYCLOBENZAPRINE 10MG (FLEXERIL) TABLET	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
CYCLOBENZAPRINE 5MG TABLET	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
CYCLOPENTOLATE 1% OPTH SOLUTION-2ML	250	RC	A9270	CPT				Both			13.86	6.24	0.01	12.47	0.01							Fee Schedule		10.26							Fee Schedule																													12.47							Fee Schedule																																															
CYCLOSPORIN ISOSPORA 10018N STOOL 10%FO	301	RC	87015	CPT				Both			206.85	93.08	5.93	186.17	5.93							Fee Schedule		7.42							Fee Schedule		6.88							Fee Schedule		6.68							Fee Schedule		6.68							Fee Schedule		186.17							Fee Schedule		7.68							Fee Schedule		6.21							Fee Schedule		6.68							Fee Schedule		7.68							Fee Schedule		6.21							Fee Schedule		
CYCLOSPORINE 15220	301	RC	80158	CPT				Both			175.35	78.91	16.04	157.82	16.04							Fee Schedule		20.06							Fee Schedule		18.59							Fee Schedule		18.05							Fee Schedule		18.05							Fee Schedule		157.82							Fee Schedule		20.76							Fee Schedule		16.79							Fee Schedule		18.05							Fee Schedule		20.76							Fee Schedule		16.79							Fee Schedule		
CYPROHEPTADINE 4MG (PERIACTIN) TABLET	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
CYSTATIN C W/EGFR 94588	301	RC	82610	CPT				Both			210	94.5	13.33	189	13.33							Fee Schedule		18.52							Fee Schedule		19.08							Fee Schedule		18.52							Fee Schedule		18.52							Fee Schedule		189							Fee Schedule		21.3							Fee Schedule		17.22							Fee Schedule		18.52							Fee Schedule		21.3							Fee Schedule		17.22							Fee Schedule		
CYSTIC FIBROSIS DNA 10458 5ML LAVENDER	310	RC	81220	CPT				Both			1050	472.5	400.75	945	400.75							Fee Schedule		556.6							Fee Schedule		573.3							Fee Schedule		556.6							Fee Schedule		556.6							Fee Schedule		945							Fee Schedule		640.09							Fee Schedule		517.64							Fee Schedule											640.09							Fee Schedule		517.64							Fee Schedule		
CYSTINE 24 HR URINE 10947	301	RC	82131	CPT				Both			111	49.95	16.55	99.9	16.55							Fee Schedule		22.98							Fee Schedule		23.67							Fee Schedule		22.98							Fee Schedule		22.98							Fee Schedule		99.9							Fee Schedule		26.43							Fee Schedule		21.37							Fee Schedule		22.98							Fee Schedule		26.43							Fee Schedule		21.37							Fee Schedule		
CYSTINE URINE RANDOM 401	301	RC	82131	CPT				Both			80.85	36.38	16.55	72.77	16.55							Fee Schedule		22.98							Fee Schedule		23.67							Fee Schedule		22.98							Fee Schedule		22.98							Fee Schedule		72.77							Fee Schedule		26.43							Fee Schedule		21.37							Fee Schedule		22.98							Fee Schedule		26.43							Fee Schedule		21.37							Fee Schedule		
CYSTO CONRAY II 0862-50	272	RC						Both			68	30.6	30.6	61.2	44.2							Fee Schedule		50.32							Fee Schedule																													61.2							Fee Schedule																																															
CYSTO IRRIGATION SET #2C4040	272	RC						Both			12	5.4	5.4	10.8	7.8							Fee Schedule		8.88							Fee Schedule																													10.8							Fee Schedule																																															
CYSTO PACK #DYNJP5020SI	270	RC						Both			27	12.15	12.15	24.3	17.55							Fee Schedule		19.98							Fee Schedule																													24.3							Fee Schedule																																															
CYSTOGRAFIN FOR VCUG	254	RC	Q9965	CPT				Both			119.7	53.87	0.7	107.73	0.88							Fee Schedule		88.58							Fee Schedule		0.77							Fee Schedule											0.75							Fee Schedule		107.73							Fee Schedule		0.86							Fee Schedule		0.7							Fee Schedule											0.86							Fee Schedule		0.7							Fee Schedule		
CYSTOGRAM	329	RC	74430	CPT				Both			315	141.75	17.93	318	17.93							Fee Schedule		20.97							Fee Schedule											29.66							Fee Schedule											283.5							Fee Schedule																				318							Per Diem																				
CYSTOGRAPHY VCU	329	RC	74455	CPT				Both			315	141.75	44.71	318	54.03							Fee Schedule		67.41							Fee Schedule											44.71							Fee Schedule											283.5							Fee Schedule																				318							Per Diem																				
CYTOCHROME P350 2D6 GENOTYPE 10490	310	RC	81226	CPT				Both			692.28	311.53	311.53	623.05	324.66							Fee Schedule		450.91							Fee Schedule		464.44							Fee Schedule		450.91							Fee Schedule		450.91							Fee Schedule		623.05							Fee Schedule		518.55							Fee Schedule		419.35							Fee Schedule											518.55							Fee Schedule		419.35							Fee Schedule		
CYTOLOGY BRUSH BC-V600P-3010	272	RC						Both			307.65	138.44	138.44	276.89	199.97							Fee Schedule		227.66							Fee Schedule																													276.89							Fee Schedule																																															
CYTOLOGY BRUSH DISP #DCB-DV-50 (COOK)	270	RC						Both			9.45	4.25	4.25	8.51	6.14							Fee Schedule		6.99							Fee Schedule																													8.51							Fee Schedule																																															
CYTOLOGY BRUSH DISP BC-202D-2010	272	RC						Both			53	23.85	23.85	47.7	34.45							Fee Schedule		39.22							Fee Schedule																													47.7							Fee Schedule																																															
CYTOLOGY NEEDLE MW-122 CONMED	272	RC						Both			169.05	76.07	76.07	152.15	109.88							Fee Schedule		125.1							Fee Schedule																													152.15							Fee Schedule																																															
CYTOLOGY NEEDLE MW1221	272	RC						Both			169.05	76.07	76.07	152.15	109.88							Fee Schedule		125.1							Fee Schedule																													152.15							Fee Schedule																																															
CYTOLOGY NEEDLE MW-222 CONMED	272	RC						Both			169.05	76.07	76.07	152.15	109.88							Fee Schedule		125.1							Fee Schedule																													152.15							Fee Schedule																																															
CYTOMAX DBL LU BRSH DLB-35-3.5-S	272	RC						Both			249	112.05	112.05	224.1	161.85							Fee Schedule		184.26							Fee Schedule																													224.1							Fee Schedule																																															
CYTOMEGALOVIRUS CULTURE 2627 SWAB	306	RC	87250	CPT				Both			124.95	56.23	17.39	112.46	17.39							Fee Schedule		21.73							Fee Schedule		20.15							Fee Schedule		19.56							Fee Schedule		19.56							Fee Schedule		112.46							Fee Schedule		22.49							Fee Schedule		18.19							Fee Schedule		19.56							Fee Schedule		22.49							Fee Schedule		18.19							Fee Schedule		
CYTOPATH CERVICAL OR VAGINAL AUTO AND MA	310	RC	88175	CPT				Both			115.5	51.98	23.55	103.95	23.55							Fee Schedule		29.44							Fee Schedule		27.41							Fee Schedule		26.61							Fee Schedule		26.61							Fee Schedule		103.95							Fee Schedule		30.6							Fee Schedule		24.75							Fee Schedule											30.6							Fee Schedule		24.75							Fee Schedule		
CYTOPATHOLOGY CERVICAL/VAGINAL	311	RC	88142	CPT				Both			94.5	42.53	18.01	85.05	18.01							Fee Schedule		22.51							Fee Schedule		20.87							Fee Schedule		20.26							Fee Schedule		20.26							Fee Schedule		85.05							Fee Schedule		23.3							Fee Schedule		18.84							Fee Schedule											23.3							Fee Schedule		18.84							Fee Schedule		
CYTOVENE IV:500 MG (GANCICLOVIR)	636	RC	J1570	CPT				Both			172.2	77.49	29.26	154.98		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	127.43							Fee Schedule		32.41							Fee Schedule		44.73							Fee Schedule		31.46							Fee Schedule		154.98							Fee Schedule		36.18							Fee Schedule		29.26							Fee Schedule											36.18							Fee Schedule		29.26							Fee Schedule		
CYTOXAN 2 GM VIAL	636	RC	J8530	CPT				Both			131.25	59.06	1.39	118.13		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	97.13							Fee Schedule		1.54							Fee Schedule											1.49							Fee Schedule		118.13							Fee Schedule		1.71							Fee Schedule		1.39							Fee Schedule											1.71							Fee Schedule		1.39							Fee Schedule		
D 50W WITH PF	258	RC						Both			86.1	38.75	38.75	77.49	55.97							Fee Schedule		63.71							Fee Schedule																													77.49							Fee Schedule																																															
D DIMER ASSAY	305	RC	85379	CPT				Both			201.6	90.72	9.04	181.44	9.04							Fee Schedule		11.31							Fee Schedule		10.49							Fee Schedule		10.18							Fee Schedule		10.18							Fee Schedule		181.44							Fee Schedule		11.71							Fee Schedule		9.47							Fee Schedule		10.18							Fee Schedule		11.71							Fee Schedule		9.47							Fee Schedule		
D DIMER ASSAY	305	RC	85379	CPT				Both			201.6	90.72	9.04	181.44	9.04							Fee Schedule		11.31							Fee Schedule		10.49							Fee Schedule		10.18							Fee Schedule		10.18							Fee Schedule		181.44							Fee Schedule		11.71							Fee Schedule		9.47							Fee Schedule		10.18							Fee Schedule		11.71							Fee Schedule		9.47							Fee Schedule		
D&E CURETTE CURVED 10MM 21553	272	RC						Both			14	6.3	6.3	12.6	9.1							Fee Schedule		10.36							Fee Schedule																													12.6							Fee Schedule																																															
D&E CURETTE CURVED 11MM 21554	272	RC						Both			14	6.3	6.3	12.6	9.1							Fee Schedule		10.36							Fee Schedule																													12.6							Fee Schedule																																															
D&E CURETTE CURVED 12MM 21555	272	RC						Both			14	6.3	6.3	12.6	9.1							Fee Schedule		10.36							Fee Schedule																													12.6							Fee Schedule																																															
D&E CURETTE CURVED 9MM 21552	272	RC						Both			14	6.3	6.3	12.6	9.1							Fee Schedule		10.36							Fee Schedule																													12.6							Fee Schedule																																															
D&E CURETTE FLEX 6MM 21665	272	RC						Both			14	6.3	6.3	12.6	9.1							Fee Schedule		10.36							Fee Schedule																													12.6							Fee Schedule																																															
D&E CURETTE FLEX 7MM 21744	272	RC						Both			14	6.3	6.3	12.6	9.1							Fee Schedule		10.36							Fee Schedule																													12.6							Fee Schedule																																															
D&E CURETTE FLEX 8MM 21745	272	RC						Both			14	6.3	6.3	12.6	9.1							Fee Schedule		10.36							Fee Schedule																													12.6							Fee Schedule																																															
D&E CURETTE STRAIGHT 10MM 21414	272	RC						Both			14	6.3	6.3	12.6	9.1							Fee Schedule		10.36							Fee Schedule																													12.6							Fee Schedule																																															
D&E CURETTE STRAIGHT 11MM 21415	272	RC						Both			14	6.3	6.3	12.6	9.1							Fee Schedule		10.36							Fee Schedule																													12.6							Fee Schedule																																															
D&E CURETTE STRAIGHT 12MM 21416	272	RC						Both			14	6.3	6.3	12.6	9.1							Fee Schedule		10.36							Fee Schedule																													12.6							Fee Schedule																																															
D&E CURETTE STRAIGHT 14MM 21464A	272	RC						Both			15	6.75	6.75	13.5	9.75							Fee Schedule		11.1							Fee Schedule																													13.5							Fee Schedule																																															
D&E CURETTE STRAIGHT 8MM 21655	272	RC						Both			14	6.3	6.3	12.6	9.1							Fee Schedule		10.36							Fee Schedule																													12.6							Fee Schedule																																															
D&E CURETTE STRAIGHT 9MM 21413	272	RC						Both			14	6.3	6.3	12.6	9.1							Fee Schedule		10.36							Fee Schedule																													12.6							Fee Schedule																																															
D&E CURETTES CURVED 7MM  21853	272	RC						Both			14	6.3	6.3	12.6	9.1							Fee Schedule		10.36							Fee Schedule																													12.6							Fee Schedule																																															
D&E CURETTES CURVED 8MM  20317	272	RC						Both			14	6.3	6.3	12.6	9.1							Fee Schedule		10.36							Fee Schedule																													12.6							Fee Schedule																																															
D&E CURETTES FLEX 8MM	272	RC						Both			14.7	6.62	6.62	13.23	9.56							Fee Schedule		10.88							Fee Schedule																													13.23							Fee Schedule																																															
D&E CURETTES STRAIGHT 7MM  21852	272	RC						Both			14	6.3	6.3	12.6	9.1							Fee Schedule		10.36							Fee Schedule																													12.6							Fee Schedule																																															
D&E DISPOSA TOP NONCONDUCTIVE	272	RC						Both			15.75	7.09	7.09	14.18	10.24							Fee Schedule		11.66							Fee Schedule																													14.18							Fee Schedule																																															
D&E TUBING 23116  (OLYMPUS)	272	RC						Both			66	29.7	29.7	59.4	42.9							Fee Schedule		48.84							Fee Schedule																													59.4							Fee Schedule																																															
D&E VACURETTE CURVED 14MM 022145	272	RC						Both			16	7.2	7.2	14.4	10.4							Fee Schedule		11.84							Fee Schedule																													14.4							Fee Schedule																																															
D12.5W 500ML	258	RC	A9270	CPT				Both			36.75	16.54	0.01	33.08	0.01							Fee Schedule		27.2							Fee Schedule																													33.08							Fee Schedule																																															
D5  L R +20 MEQ KCL/1000ML(32B224)	258	RC						Both			6.3	2.84	2.84	5.67	4.1							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
D5 1/2 NS 1000 KCL 10	258	RC						Both			33.6	15.12	15.12	30.24	21.84							Fee Schedule		24.86							Fee Schedule																													30.24							Fee Schedule																																															
D5 1/2 NS 1000 KCL 20	258	RC						Both			33.6	15.12	15.12	30.24	21.84							Fee Schedule		24.86							Fee Schedule																													30.24							Fee Schedule																																															
D5 1/2 NS 1000 KCL 30	258	RC						Both			5.25	2.36	2.36	4.73	3.41							Fee Schedule		3.89							Fee Schedule																													4.73							Fee Schedule																																															
D5 1/2NS+KCL 10 MEQ 1000ML	636	RC	J3480	CPT				Both			48.3	21.74	0.13	43.47		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	35.74							Fee Schedule		0.14							Fee Schedule		0.27							Fee Schedule		0.14							Fee Schedule		43.47							Fee Schedule		0.16							Fee Schedule		0.13							Fee Schedule											0.16							Fee Schedule		0.13							Fee Schedule		
D5 1/2NS+KCL 10 MEQ 500ML VOLUTROL	636	RC	J3480	CPT				Both			29.38	13.22	0.13	26.44		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	21.74							Fee Schedule		0.14							Fee Schedule		0.27							Fee Schedule		0.14							Fee Schedule		26.44							Fee Schedule		0.16							Fee Schedule		0.13							Fee Schedule											0.16							Fee Schedule		0.13							Fee Schedule		
D5 1/2NS+KCL 20 MEQ 1000ML	636	RC	J3480	CPT				Both			21	9.45	0.13	18.9		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	15.54							Fee Schedule		0.14							Fee Schedule		0.27							Fee Schedule		0.14							Fee Schedule		18.9							Fee Schedule		0.16							Fee Schedule		0.13							Fee Schedule											0.16							Fee Schedule		0.13							Fee Schedule		
D5 1/2NS+KCL 30 MEQ 1000ML	636	RC	J3480	CPT				Both			48.3	21.74	0.13	43.47		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	35.74							Fee Schedule		0.14							Fee Schedule		0.27							Fee Schedule		0.14							Fee Schedule		43.47							Fee Schedule		0.16							Fee Schedule		0.13							Fee Schedule											0.16							Fee Schedule		0.13							Fee Schedule		
D5 1/2NS+KCL 40 MEQ 1000ML	636	RC	J3480	CPT				Both			36.75	16.54	0.13	33.08		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	27.2							Fee Schedule		0.14							Fee Schedule		0.27							Fee Schedule		0.14							Fee Schedule		33.08							Fee Schedule		0.16							Fee Schedule		0.13							Fee Schedule											0.16							Fee Schedule		0.13							Fee Schedule		
D5 1/4NS + 10 MEQ KCL/500ML	636	RC	J3480	CPT				Both			56.7	25.52	0.13	51.03		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	41.96							Fee Schedule		0.14							Fee Schedule		0.27							Fee Schedule		0.14							Fee Schedule		51.03							Fee Schedule		0.16							Fee Schedule		0.13							Fee Schedule											0.16							Fee Schedule		0.13							Fee Schedule		
D5 ALCOHOL 5	258	RC						Both			49.35	22.21	22.21	44.42	32.08							Fee Schedule		36.52							Fee Schedule																													44.42							Fee Schedule																																															
D5LR + 20 MEQ KCL/1000ML	258	RC	J3480	CPT				Both			30.45	13.7	0.13	27.41	0.14							Fee Schedule		22.53							Fee Schedule		0.14							Fee Schedule		0.27							Fee Schedule		0.14							Fee Schedule		27.41							Fee Schedule		0.16							Fee Schedule		0.13							Fee Schedule											0.16							Fee Schedule		0.13							Fee Schedule		
D5LR 500ML #2B2073Q	258	RC						Both			3.15	1.42	1.42	2.84	2.05							Fee Schedule		2.33							Fee Schedule																													2.84							Fee Schedule																																															
D5NS+ 20 MEQ KCL/1000ML	258	RC	J3480	CPT				Both			47.25	21.26	0.13	42.53	0.14							Fee Schedule		34.97							Fee Schedule		0.14							Fee Schedule		0.27							Fee Schedule		0.14							Fee Schedule		42.53							Fee Schedule		0.16							Fee Schedule		0.13							Fee Schedule											0.16							Fee Schedule		0.13							Fee Schedule		
D5NS+ 40 MEQ KCL/1000ML	258	RC	J7042	CPT				Both			47.25	21.26	0.93	42.53	0.93							Fee Schedule		34.97							Fee Schedule		1.25							Fee Schedule		13.42							Fee Schedule		1.22							Fee Schedule		42.53							Fee Schedule		1.4							Fee Schedule		1.13							Fee Schedule											1.4							Fee Schedule		1.13							Fee Schedule		
D5RL 1000	258	RC	J7121	CPT				Both			33.6	15.12	4.95	30.24	4.95							Fee Schedule		24.86							Fee Schedule																													30.24							Fee Schedule																																															
D5W  100 ML MINI-BAG PLUS	258	RC						Both			27.3	12.29	12.29	24.57	17.75							Fee Schedule		20.2							Fee Schedule																													24.57							Fee Schedule																																															
D5W  150 ML	258	RC						Both			18.9	8.51	8.51	17.01	12.29							Fee Schedule		13.99							Fee Schedule																													17.01							Fee Schedule																																															
D5W  500 ML FOR CORDARONE	250	RC						Both			23.1	10.4	10.4	20.79	15.02							Fee Schedule		17.09							Fee Schedule																													20.79							Fee Schedule																																															
D5W 100CC	258	RC	J7060	CPT				Both			25.2	11.34	1.53	22.68	1.82							Fee Schedule		18.65							Fee Schedule		1.7							Fee Schedule		13.82							Fee Schedule		1.65							Fee Schedule		22.68							Fee Schedule		1.9							Fee Schedule		1.53							Fee Schedule											1.9							Fee Schedule		1.53							Fee Schedule		
D5W 250	258	RC						Both			3.15	1.42	1.42	2.84	2.05							Fee Schedule		2.33							Fee Schedule																													2.84							Fee Schedule																																															
D5W 50 CC	258	RC						Both			25.2	11.34	11.34	22.68	16.38							Fee Schedule		18.65							Fee Schedule																													22.68							Fee Schedule																																															
D5W 50 CC	258	RC	J7060	CPT				Both			24.15	10.87	1.53	21.74	1.82							Fee Schedule		17.87							Fee Schedule		1.7							Fee Schedule		13.82							Fee Schedule		1.65							Fee Schedule		21.74							Fee Schedule		1.9							Fee Schedule		1.53							Fee Schedule											1.9							Fee Schedule		1.53							Fee Schedule		
D5W 50 QUAD	258	RC						Both			21	9.45	9.45	18.9	13.65							Fee Schedule		15.54							Fee Schedule																													18.9							Fee Schedule																																															
D5W 500ML  IN PLASTICBOTTLES #6E-0063	258	RC						Both			11.55	5.2	5.2	10.4	7.51							Fee Schedule		8.55							Fee Schedule																													10.4							Fee Schedule																																															
DAILY AEROCLIPSE # 58-65050EEA	271	RC						Both			19.95	8.98	8.98	17.96	12.97							Fee Schedule		14.76							Fee Schedule																													17.96							Fee Schedule																																															
DAILY AEROSOL SUPPLY	271	RC						Both			13.65	6.14	6.14	12.29	8.87							Fee Schedule		10.1							Fee Schedule																													12.29							Fee Schedule																																															
DAILY IPPB SUPPLY	271	RC						Both			11.55	5.2	5.2	10.4	7.51							Fee Schedule		8.55							Fee Schedule																													10.4							Fee Schedule																																															
DAKINS SOLUTION (0.125%) 480ML	250	RC	A9270	CPT				Both			76.05	34.22	0.01	68.45	0.01							Fee Schedule		56.28							Fee Schedule																													68.45							Fee Schedule																																															
DAKINS SOLUTION 5% 16OZ #00436094616	270	RC	A6260	CPT				Both			71	31.95	0.52	63.9	0.52							Fee Schedule		52.54							Fee Schedule																													63.9							Fee Schedule																																															
DALIRESP (ROFLUMILAST) 500MCG TABLET	250	RC	A9270	CPT				Both			36.75	16.54	0.01	33.08	0.01							Fee Schedule		27.2							Fee Schedule																													33.08							Fee Schedule																																															
DALVANCE 1500MG/D5W 500ML	636	RC	J0875	CPT				Both			19214.64	8646.59	14.5	17293.18		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	15							Fee Schedule		16.06							Fee Schedule											15.59							Fee Schedule		17293.18							Fee Schedule		17.93							Fee Schedule		14.5							Fee Schedule											17.93							Fee Schedule		14.5							Fee Schedule		
DALVANCE 500MG VIAL	636	RC	J0875	CPT				Both			6404.88	2882.2	14.5	5764.39		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	15							Fee Schedule		16.06							Fee Schedule											15.59							Fee Schedule		5764.39							Fee Schedule		17.93							Fee Schedule		14.5							Fee Schedule											17.93							Fee Schedule		14.5							Fee Schedule		
DANOCRINE 200 MG CAPSULE	250	RC	A9270	CPT				Both			9.2	4.14	0.01	8.28	0.01							Fee Schedule		6.81							Fee Schedule																													8.28							Fee Schedule																																															
DANTROLENE (DANTRIUM ) 20 MG VIAL	250	RC	A9270	CPT				Both			311.28	140.08	0.01	280.15	0.01							Fee Schedule		230.35							Fee Schedule																													280.15							Fee Schedule																																															
DANTROLENE 25MG (DANTRIUM) CAPSULE	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
DAPSONE 100 MG TABLET	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
DAPTACEL (DTaP)  VACCINE <7YRS	636	RC	90700	CPT				Both			54.6	24.57	24.57	49.14		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	40.4							Fee Schedule											32.47							Fee Schedule											49.14							Fee Schedule																																															
DAPTOMYCIN 500MG (CUBICIN) IVPB	636	RC	J0878	CPT				Both			1602	720.9	0.03	1441.8		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1185.48							Fee Schedule		0.03							Fee Schedule											0.03							Fee Schedule		1441.8							Fee Schedule		0.03							Fee Schedule		0.03							Fee Schedule											0.03							Fee Schedule		0.03							Fee Schedule		
DAPTOMYCIN 500MG VIAL	636	RC	J0878	CPT				Both			1486.83	669.07	0.03	1338.15		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1100.25							Fee Schedule		0.03							Fee Schedule											0.03							Fee Schedule		1338.15							Fee Schedule		0.03							Fee Schedule		0.03							Fee Schedule											0.03							Fee Schedule		0.03							Fee Schedule		
DAVOL STAPLING DEVICE HERNIA #0113077	272	RC						Both			1572.9	707.81	707.81	1415.61	1022.39							Fee Schedule		1163.95							Fee Schedule																													1415.61							Fee Schedule																																															
DAW- ESOMEPRAZOLE 40 MG (NEXIUM) CAP	250	RC	A9270	CPT				Both			14.7	6.62	0.01	13.23	0.01							Fee Schedule		10.88							Fee Schedule																													13.23							Fee Schedule																																															
DAYPRO 600 MG TABLET	250	RC	A9270	CPT				Both			4.25	1.91	0.01	3.83	0.01							Fee Schedule		3.15							Fee Schedule																													3.83							Fee Schedule																																															
DBX MIX 10CC #058100 (MTF)	278	RC	C9359	CPT				Both			4371.15	1967.02	1967.02	3934.04		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	3234.65							Fee Schedule																													3934.04							Fee Schedule																																															
DDAVP INJECTION 4MCG/ML 1 ML AMP	250	RC	J2597	CPT				Both			283.5	127.58	3.31	255.15	11.52							Fee Schedule		209.79							Fee Schedule		3.67							Fee Schedule		7.07							Fee Schedule		3.56							Fee Schedule		255.15							Fee Schedule		4.1							Fee Schedule		3.31							Fee Schedule											4.1							Fee Schedule		3.31							Fee Schedule		
DEBAKEY BLADE  374810  ( SENECA )	272	RC						Both			16.28	7.33	7.33	14.65	10.58							Fee Schedule		12.05							Fee Schedule																													14.65							Fee Schedule																																															
DEBRIDEMENT I	420	RC	11000	CPT				Both			315	141.75	141.75	318	200							Per Diem		233.1							Fee Schedule																													283.5							Fee Schedule																				318							Per Diem																				
DEBRIDEMENT II	420	RC	11000	CPT				Both			315	141.75	141.75	318	200							Per Diem		233.1							Fee Schedule																													283.5							Fee Schedule																				318							Per Diem																				
DEBRISOFT LOLLY #DEB001Z	272	RC	A4649	CPT				Both			27.8	12.51	12.51	25.02	18.07							Fee Schedule		20.57							Fee Schedule																													25.02							Fee Schedule																																															
DECADRON ELIXIR 0.5MG/5ML(PER OZ)	250	RC	A9270	CPT				Both			8.4	3.78	0.01	7.56	0.01							Fee Schedule		6.22							Fee Schedule																													7.56							Fee Schedule																																															
DECADRON LA 8	636	RC	J1094	CPT				Both			10.5	4.73	4.73	9.45		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	7.77							Fee Schedule																													9.45							Fee Schedule																																															
DECALCIFICATION TISSUE	312	RC	88311	CPT				Both			85.05	38.27	5.97	76.55	5.97							Fee Schedule		7.98							Fee Schedule											7.51							Fee Schedule											76.55							Fee Schedule																																															
DECLOMYCIN 150 MG TABLET UD	250	RC	A9270	CPT				Both			41.64	18.74	0.01	37.48	0.01							Fee Schedule		30.81							Fee Schedule																													37.48							Fee Schedule																																															
DECOMPRESSION NEEDLE 14GX31/4   ZZ-0056	272	RC						Both			33	14.85	14.85	29.7	21.45							Fee Schedule		24.42							Fee Schedule																													29.7							Fee Schedule																																															
DECOMPRESSION TUBE	272	RC						Both			45.15	20.32	20.32	40.64	29.35							Fee Schedule		33.41							Fee Schedule																													40.64							Fee Schedule																																															
DEEP SCROTAL RETRACTION SYSTEM 72403867	272	RC						Both			1680	756	756	1512	1092							Fee Schedule		1243.2							Fee Schedule																													1512							Fee Schedule																																															
DEEP SEA 0.65% NASAL SOLUTION-45ML	250	RC	A9270	CPT				Both			7.35	3.31	0.01	6.62	0.01							Fee Schedule		5.44							Fee Schedule																													6.62							Fee Schedule																																															
DEFEROXAMINE 2GM VIAL	636	RC	J0895	CPT				Both			119.7	53.87	9.32	107.73		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	88.58							Fee Schedule		10.32							Fee Schedule		13.29							Fee Schedule		10.02							Fee Schedule		107.73							Fee Schedule		11.52							Fee Schedule		9.32							Fee Schedule											11.52							Fee Schedule		9.32							Fee Schedule		
DEFEROXAMINE 2GM/NS 600ML IVPB	636	RC	J0895	CPT				Both			148.32	66.74	9.32	133.49		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	109.76							Fee Schedule		10.32							Fee Schedule		13.29							Fee Schedule		10.02							Fee Schedule		133.49							Fee Schedule		11.52							Fee Schedule		9.32							Fee Schedule											11.52							Fee Schedule		9.32							Fee Schedule		
DEFIB PADS PEDIATRIC CONMED #2603R	271	RC						Both			61.95	27.88	27.88	55.76	40.27							Fee Schedule		45.84							Fee Schedule																													55.76							Fee Schedule																																															
DEFIBRILLATOR PAPER FOR ZOLL #8000-00087	271	RC						Both			11	4.95	4.95	9.9	7.15							Fee Schedule		8.14							Fee Schedule																													9.9							Fee Schedule																																															
DEFINITY DE16	272	RC	Q9967	CPT				Both			424	190.8	0.12	381.6	0.12							Fee Schedule		313.76							Fee Schedule		0.16							Fee Schedule											0.16							Fee Schedule		381.6							Fee Schedule		0.18							Fee Schedule		0.14							Fee Schedule											0.18							Fee Schedule		0.14							Fee Schedule		
DEFINITY US CONTRAST	483	RC	C8921	CPT				Both			500	225	225	921.04	420							Per Diem		370							Fee Schedule		824.93							Fee Schedule											800.9							Fee Schedule		450							Fee Schedule		921.04							Fee Schedule		744.84							Fee Schedule		668							Per Diem		921.04							Fee Schedule		744.84							Fee Schedule		
AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIM					240	DRG		Inpatient			83612.2	37625.49	37625.49	37625.49							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period	
DELATESTRYL 200 MG/ML-5ML VIAL	636	RC	J3121	CPT				Both			64.05	28.82	0.05	57.65		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	47.4							Fee Schedule		0.05							Fee Schedule											0.05							Fee Schedule		57.65							Fee Schedule		0.06							Fee Schedule		0.05							Fee Schedule											0.06							Fee Schedule		0.05							Fee Schedule		
DELEE SUCTION  DYND44110	272	RC						Both			4	1.8	1.8	3.6	2.6							Fee Schedule		2.96							Fee Schedule																													3.6							Fee Schedule																																															
DELESTROGEN 20MG/ML-5ML VIAL	636	RC	J1380	CPT				Both			141.75	63.79	2.1	127.58		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	104.9							Fee Schedule		7.93							Fee Schedule		2.1							Fee Schedule		7.7							Fee Schedule		127.58							Fee Schedule		8.86							Fee Schedule		7.16							Fee Schedule											8.86							Fee Schedule		7.16							Fee Schedule		
DELIVERY ROOM	720	RC						Inpatient			787.5	354.38	11.26	796	500							Per Diem		582.75							Fee Schedule											11.26							Fee Schedule											708.75							Fee Schedule																				796							Case Rate																				
DELSYM 12 HR-30MG/5ML 90ML	250	RC	A9270	CPT				Both			21.99	9.9	0.01	19.79	0.01							Fee Schedule		16.27							Fee Schedule																													19.79							Fee Schedule																																															
DELSYM 12 HR-30MG/5ML UD	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
DELZICOL (MESALAMINE) 400MG TABLET	250	RC	A9270	CPT				Both			8.4	3.78	0.01	7.56	0.01							Fee Schedule		6.22							Fee Schedule																													7.56							Fee Schedule																																															
DEMADEX 20 MG TABLET	250	RC	A9270	CPT				Both			4.2	1.89	0.01	3.78	0.01							Fee Schedule		3.11							Fee Schedule																													3.78							Fee Schedule																																															
DEMECLOCYCLINE 150MG TABLET	250	RC	A9270	CPT				Both			28.2	12.69	0.01	25.38	0.01							Fee Schedule		20.87							Fee Schedule																													25.38							Fee Schedule																																															
DEMECLOCYCLINE 300MG TABLET	250	RC	A9270	CPT				Both			107.1	48.2	0.01	96.39	0.01							Fee Schedule		79.25							Fee Schedule																													96.39							Fee Schedule																																															
DEMEROL 100 MG/ML INJECTION	636	RC	J2175	CPT				Both			18.38	8.27	1.31	16.54		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	13.6							Fee Schedule		6.53							Fee Schedule		1.31							Fee Schedule		6.34							Fee Schedule		16.54							Fee Schedule		7.29							Fee Schedule		5.9							Fee Schedule											7.29							Fee Schedule		5.9							Fee Schedule		
DEMEROL PCA 50 ML SYRINGE/BAG	636	RC	J2175	CPT				Both			84	37.8	1.31	75.6		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	62.16							Fee Schedule		6.53							Fee Schedule		1.31							Fee Schedule		6.34							Fee Schedule		75.6							Fee Schedule		7.29							Fee Schedule		5.9							Fee Schedule											7.29							Fee Schedule		5.9							Fee Schedule		
UPPER LIMB AND TOE AMPUTATION FOR CIRCULATORY SYSTEM DISORDE					256	DRG		Inpatient			24976.37	11239.37	11239.37	11239.37							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period							0		No services provided during 15 month lookback period				9028.52	9028.52	9028.52	1 through 10									0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period	
OTHER CIRCULATORY SYSTEM O.R. PROCEDURES					264	DRG		Inpatient			51250.61	23062.77	23062.77	23062.77							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period	
DENTAL ROLL 32-330  ( CONCORDANCE )	272	RC						Both			3.6	1.62	1.62	3.24	2.34							Fee Schedule		2.66							Fee Schedule																													3.24							Fee Schedule																																															
DENVER ASCITES SHUNT	278	RC						Both			5995.5	2697.98	2697.98	5395.95		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	4436.67							Fee Schedule																													5395.95							Fee Schedule																																															
DENVER SHUNT INTRO.  10383-006	272	RC						Both			277.2	124.74	124.74	249.48	180.18							Fee Schedule		205.13							Fee Schedule																													249.48							Fee Schedule																																															
DENVER SHUNT INTRODUCER 10383-010	272	RC						Both			277.2	124.74	124.74	249.48	180.18							Fee Schedule		205.13							Fee Schedule																													249.48							Fee Schedule																																															
DENVER SHUNT INTRODUCER#10383-006	272	RC						Both			277.2	124.74	124.74	249.48	180.18							Fee Schedule		205.13							Fee Schedule																													249.48							Fee Schedule																																															
DENVER SPLINT LARGE #10-1500-KL ( SENECA	270	RC						Both			136.5	61.43	61.43	122.85	88.73							Fee Schedule		101.01							Fee Schedule																													122.85							Fee Schedule																																															
DENVER SPLINT PETITE   10-1500-05KP	270	RC						Both			203	91.35	91.35	182.7	131.95							Fee Schedule		150.22							Fee Schedule																													182.7							Fee Schedule																																															
DENVER SPLINT SM/MED 10-1500-05KS	270	RC						Both			144.9	65.21	65.21	130.41	94.19							Fee Schedule		107.23							Fee Schedule																													130.41							Fee Schedule																																															
DEPAKENE VALPORIC ACID	301	RC	80164	CPT				Both			191.1	86	12.04	171.99	12.04							Fee Schedule		15.05							Fee Schedule		13.95							Fee Schedule		13.54							Fee Schedule		13.54							Fee Schedule		171.99							Fee Schedule		15.57							Fee Schedule		12.59							Fee Schedule		13.54							Fee Schedule		15.57							Fee Schedule		12.59							Fee Schedule		
DEPO ESTRADIOL 5 MG/ML- 5ML VIAL	636	RC	J1000	CPT				Both			69.3	31.19	1.29	62.37		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	51.28							Fee Schedule		55.43							Fee Schedule		1.29							Fee Schedule		53.81							Fee Schedule		62.37							Fee Schedule		61.88							Fee Schedule		50.04							Fee Schedule											61.88							Fee Schedule		50.04							Fee Schedule		
DEPO TESTOSTERONE 100 MG/ML- 10 ML VIAL	636	RC	J1071	CPT				Both			24.15	10.87	0.02	21.74		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	17.87							Fee Schedule		0.03							Fee Schedule											0.03							Fee Schedule		21.74							Fee Schedule		0.03							Fee Schedule		0.02							Fee Schedule											0.03							Fee Schedule		0.02							Fee Schedule		
DEPO TESTOSTERONE 200 MG/ML- 1ML VIAL	636	RC	J1071	CPT				Both			90.3	40.64	0.02	81.27		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	66.82							Fee Schedule		0.03							Fee Schedule											0.03							Fee Schedule		81.27							Fee Schedule		0.03							Fee Schedule		0.02							Fee Schedule											0.03							Fee Schedule		0.02							Fee Schedule		
DEPO TESTOSTERONE 200 MG/ML-1ML VIAL	636	RC	J1071	CPT				Both			9.45	4.25	0.02	8.51		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	6.99							Fee Schedule		0.03							Fee Schedule											0.03							Fee Schedule		8.51							Fee Schedule		0.03							Fee Schedule		0.02							Fee Schedule											0.03							Fee Schedule		0.02							Fee Schedule		
DEPO-MEDROL 40MG/ ML VIAL	636	RC	J1010	CPT				Both			33.6	15.12	0.11	30.24		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	24.86							Fee Schedule		0.12							Fee Schedule											0.12							Fee Schedule		30.24							Fee Schedule		0.13							Fee Schedule		0.11							Fee Schedule											0.13							Fee Schedule		0.11							Fee Schedule		
DEPO-MEDROL 40MG/ML- 10ML VIAL	636	RC	J1030	CPT				Both			19.16	8.62	8.62	17.24		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	14.18							Fee Schedule																													17.24							Fee Schedule																																															
DEPO-MEDROL 80MG/ML INJECTION	636	RC	J1010	CPT				Both			51.43	23.14	0.11	46.29		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	38.06							Fee Schedule		0.12							Fee Schedule											0.12							Fee Schedule		46.29							Fee Schedule		0.13							Fee Schedule		0.11							Fee Schedule											0.13							Fee Schedule		0.11							Fee Schedule		
DEPO-PROVERA 150MG/ML INJECTION (PT MED)	636	RC	J1050	CPT				Both			170.1	76.55	76.55	153.09		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	125.87							Fee Schedule																													153.09							Fee Schedule																																															
DEPUY EXPRESSEW II  214141  J&J  MEDLINE	272	RC						Both			1141	513.45	513.45	1026.9	741.65							Fee Schedule		844.34							Fee Schedule																													1026.9							Fee Schedule																																															
DEPUY EXPRESSEW III  214140  J&J	272	RC						Both			26682	12006.9	12006.9	24013.8	17343.3							Fee Schedule		19744.68							Fee Schedule																													24013.8							Fee Schedule																																															
DEPUY FX STEM 6MM #1128-06-000	278	RC	C1776	CPT				Both			7417.2	3337.74	3337.74	6675.48		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	5488.73							Fee Schedule																													6675.48							Fee Schedule																																															
DEPUY HIP STEM W/POROCOAT #1554-04-000	278	RC	C1776	CPT				Both			15394.05	6927.32	6927.32	13854.65		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	11391.6							Fee Schedule																													13854.65							Fee Schedule																																															
DEPUY KAMVAC 530020500	272	RC						Both			273	122.85	122.85	245.7	177.45							Fee Schedule		202.02							Fee Schedule																													245.7							Fee Schedule																																															
DEPUY MINISCAL APPLIER 228000	272	RC						Both			514.5	231.53	231.53	463.05	334.43							Fee Schedule		380.73							Fee Schedule																													463.05							Fee Schedule																																															
DERMABLADE BIOPSY ASCSC1135000Z	272	RC						Both			9	4.05	4.05	8.1	5.85							Fee Schedule		6.66							Fee Schedule																													8.1							Fee Schedule																																															
DERMABOND DNX12	272	RC						Both			71	31.95	31.95	63.9	46.15							Fee Schedule		52.54							Fee Schedule																													63.9							Fee Schedule																																															
DERMABOND PEN DNX12	272	RC						Both			52	23.4	23.4	46.8	33.8							Fee Schedule		38.48							Fee Schedule																													46.8							Fee Schedule																																															
DERMABOND PRINEO CLR222US	272	RC	G0168	CPT				Both			233	104.85	29.43	209.7	29.43							Fee Schedule		172.42							Fee Schedule																													209.7							Fee Schedule																																															
DERMABOND PRINEO CLR602US	272	RC	G0168	CPT				Both			402	180.9	29.43	361.8	29.43							Fee Schedule		297.48							Fee Schedule																													361.8							Fee Schedule																																															
DERMABOND/ SKIN AFFIX E.R. (MEDLINE)	272	RC	G0168	CPT				Both			32	14.4	14.4	29.43	29.43							Fee Schedule		23.68							Fee Schedule																													28.8							Fee Schedule																																															
DERMACEA 3X8 DRESSING 8886834100	272	RC	A6252	CPT				Both			10	4.5	2.94	9	2.94							Fee Schedule		7.4							Fee Schedule		4.78							Fee Schedule		3.67							Fee Schedule		4.64							Fee Schedule		9							Fee Schedule		5.34							Fee Schedule		4.32							Fee Schedule											5.34							Fee Schedule		4.32							Fee Schedule		
DERMADRESS 4X10 DRT12410	270	RC	A6255	CPT				Both			14	6.3	2.74	12.6	2.74							Fee Schedule		10.36							Fee Schedule		4.47							Fee Schedule		3.42							Fee Schedule		4.34							Fee Schedule		12.6							Fee Schedule		4.99							Fee Schedule		4.04							Fee Schedule											4.99							Fee Schedule		4.04							Fee Schedule		
DERMAL CURETTE 3MM #MDS0033530M	272	RC						Both			5	2.25	2.25	4.5	3.25							Fee Schedule		3.7							Fee Schedule																													4.5							Fee Schedule																																															
DERMAL CURETTE 4MM #MDS0033540M	272	RC						Both			5	2.25	2.25	4.5	3.25							Fee Schedule		3.7							Fee Schedule																													4.5							Fee Schedule																																															
DERMAL CURETTE 5MM #MDS0033550M	272	RC						Both			5	2.25	2.25	4.5	3.25							Fee Schedule		3.7							Fee Schedule																													4.5							Fee Schedule																																															
DERMAL CURETTE 7MM #MDS0033570M	272	RC						Both			5	2.25	2.25	4.5	3.25							Fee Schedule		3.7							Fee Schedule																													4.5							Fee Schedule																																															
DERMATONE BLADE (ZIMMER)	272	RC						Both			302.4	136.08	136.08	272.16	196.56							Fee Schedule		223.78							Fee Schedule																													272.16							Fee Schedule																																															
DEROYAL EXTENDED EVAC. PENCIL #88000722	272	RC						Both			140.7	63.32	63.32	126.63	91.46							Fee Schedule		104.12							Fee Schedule																													126.63							Fee Schedule																																															
DEROYAL GU/GYN ROBOTIC PACK DO NOT ORDER	272	RC						Both			240	108	108	216	156							Fee Schedule		177.6							Fee Schedule																													216							Fee Schedule																																															
DEROYAL YELLOW PAD #M15-2072R	270	RC						Both			26	11.7	11.7	23.4	16.9							Fee Schedule		19.24							Fee Schedule																													23.4							Fee Schedule																																															
DESFERAL 500 MG VIAL	636	RC	J0895	CPT				Both			46.99	21.15	9.32	42.29		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	34.77							Fee Schedule		10.32							Fee Schedule		13.29							Fee Schedule		10.02							Fee Schedule		42.29							Fee Schedule		11.52							Fee Schedule		9.32							Fee Schedule											11.52							Fee Schedule		9.32							Fee Schedule		
DES-GAMMA-CARBOXY PROTHROMBIN 19982	310	RC	83951	CPT				Both			585	263.25	57.25	526.5	57.25							Fee Schedule		71.57							Fee Schedule		66.34							Fee Schedule		64.41							Fee Schedule		64.41							Fee Schedule		526.5							Fee Schedule		74.07							Fee Schedule		59.9							Fee Schedule											74.07							Fee Schedule		59.9							Fee Schedule		
DESIPRAMINE 412 SERUM	301	RC	80307	CPT				Both			69.3	31.19	31.19	71.46	51.72							Fee Schedule		64.65							Fee Schedule		64							Fee Schedule		62.14							Fee Schedule		62.14							Fee Schedule		62.37							Fee Schedule		71.46							Fee Schedule		57.79							Fee Schedule		62.14							Fee Schedule		71.46							Fee Schedule		57.79							Fee Schedule		
DESIPRMAINE 25 MG TABLET UD	250	RC	A9270	CPT				Both			4.2	1.89	0.01	3.78	0.01							Fee Schedule		3.11							Fee Schedule																													3.78							Fee Schedule																																															
DESMOGLEIN (AB 1&3) 16033 1ML SERUM REF	301	RC	83520	CPT				Both			57.75	25.99	12.43	51.98	12.43							Fee Schedule		17.27							Fee Schedule		17.79							Fee Schedule		17.27							Fee Schedule		17.27							Fee Schedule		51.98							Fee Schedule		19.86							Fee Schedule		16.06							Fee Schedule		17.27							Fee Schedule		19.86							Fee Schedule		16.06							Fee Schedule		
DESMOPRESSIN (DDAVP) DRIP IVPB	636	RC	J2597	CPT				Both			1685.25	758.36	3.31	1516.73		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1247.09							Fee Schedule		3.67							Fee Schedule		7.07							Fee Schedule		3.56							Fee Schedule		1516.73							Fee Schedule		4.1							Fee Schedule		3.31							Fee Schedule											4.1							Fee Schedule		3.31							Fee Schedule		
DESMOPRESSIN 4 MCG/ML (DDAVP) VIAL-10ML	636	RC	J2597	CPT				Both			1685.25	758.36	3.31	1516.73		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1247.09							Fee Schedule		3.67							Fee Schedule		7.07							Fee Schedule		3.56							Fee Schedule		1516.73							Fee Schedule		4.1							Fee Schedule		3.31							Fee Schedule											4.1							Fee Schedule		3.31							Fee Schedule		
DESMOPRESSIN ACETATE NASAL SOL 0.01%	250	RC	A9270	CPT				Both			744.45	335	0.01	670.01	0.01							Fee Schedule		550.89							Fee Schedule																													670.01							Fee Schedule																																															
DESOXIMETASONE (TOPICORT) 0.25% CREAM	250	RC	A9270	CPT				Both			45.15	20.32	0.01	40.64	0.01							Fee Schedule		33.41							Fee Schedule																													40.64							Fee Schedule																																															
DETERM HISTO OR CYTOCHEM	310	RC	88319	CPT				Both			300.3	135.14	40.07	270.27	40.07							Fee Schedule		63.83							Fee Schedule											97.17							Fee Schedule											270.27							Fee Schedule																																															
DETERMINATIVE HISTOCHEMISTRY	310	RC	88313	CPT				Both			1947.75	876.49	38.44	1752.98	38.44							Fee Schedule		55.07							Fee Schedule											62.67							Fee Schedule											1752.98							Fee Schedule																																															
DEVICOR MRI PROBE SET MRP08S	272	RC						Both			1278	575.1	575.1	1150.2	830.7							Fee Schedule		945.72							Fee Schedule																													1150.2							Fee Schedule																																															
DEVICOR TARGETING SET MRU08S	272	RC						Both			1184	532.8	532.8	1065.6	769.6							Fee Schedule		876.16							Fee Schedule																													1065.6							Fee Schedule																																															
DEWRAP LAYER SYSTEM 46-333	272	RC	A6443	CPT				Both			26	11.7	0.25	23.4	0.25							Fee Schedule		19.24							Fee Schedule		0.41							Fee Schedule		0.26							Fee Schedule		0.4							Fee Schedule		23.4							Fee Schedule		0.46							Fee Schedule		0.37							Fee Schedule											0.46							Fee Schedule		0.37							Fee Schedule		
DEXA SCAN	320	RC	77080	CPT				Both			252	113.4	26.08	318	26.08							Fee Schedule		27.47							Fee Schedule											71.07							Fee Schedule											226.8							Fee Schedule																				318							Per Diem																				
DEXA SCAN PERIPHERAL EXTREMITY	320	RC	77081	CPT				Both			84	37.8	14.14	318	14.14							Fee Schedule		20.97							Fee Schedule											20.49							Fee Schedule											75.6							Fee Schedule																				318							Per Diem																				
DEXAMETHASONE 0.1% OPTHL SOLN- 5ML	250	RC	A9270	CPT				Both			54.53	24.54	0.01	49.08	0.01							Fee Schedule		40.35							Fee Schedule																													49.08							Fee Schedule																																															
DEXAMETHASONE 10MG/ML INJECTION-PF	636	RC	J1100	CPT				Both			12.6	5.67	0.08	11.34		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	9.32							Fee Schedule		0.09							Fee Schedule		0.69							Fee Schedule		0.09							Fee Schedule		11.34							Fee Schedule		0.1							Fee Schedule		0.08							Fee Schedule											0.1							Fee Schedule		0.08							Fee Schedule		
DEXAMETHASONE 10MG/ML VIA SYR PUMP-PF	636	RC	J1100	CPT				Both			12.6	5.67	0.08	11.34		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	9.32							Fee Schedule		0.09							Fee Schedule		0.69							Fee Schedule		0.09							Fee Schedule		11.34							Fee Schedule		0.1							Fee Schedule		0.08							Fee Schedule											0.1							Fee Schedule		0.08							Fee Schedule		
DEXAMETHASONE 2 MG TABLET	250	RC	J8540	CPT				Both			5.25	2.36	0.02	4.73	0.02							Fee Schedule		3.89							Fee Schedule		0.03							Fee Schedule											0.03							Fee Schedule		4.73							Fee Schedule		0.03							Fee Schedule		0.02							Fee Schedule											0.03							Fee Schedule		0.02							Fee Schedule		
DEXAMETHASONE 29391 1 ML SERUM RED TUBE	301	RC	80299	CPT				Both			199.5	89.78	13.42	179.55	13.42							Fee Schedule		18.64							Fee Schedule		19.2							Fee Schedule		18.64							Fee Schedule		18.64							Fee Schedule		179.55							Fee Schedule		21.44							Fee Schedule		17.34							Fee Schedule		18.64							Fee Schedule		21.44							Fee Schedule		17.34							Fee Schedule		
DEXAMETHASONE 4 MG/ML INJECTION	636	RC	J1100	CPT				Both			12.6	5.67	0.08	11.34		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	9.32							Fee Schedule		0.09							Fee Schedule		0.69							Fee Schedule		0.09							Fee Schedule		11.34							Fee Schedule		0.1							Fee Schedule		0.08							Fee Schedule											0.1							Fee Schedule		0.08							Fee Schedule		
DEXAMETHASONE 4 MG/ML VIAL-SYRINGE PUMP	636	RC	J1100	CPT				Both			12.6	5.67	0.08	11.34		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	9.32							Fee Schedule		0.09							Fee Schedule		0.69							Fee Schedule		0.09							Fee Schedule		11.34							Fee Schedule		0.1							Fee Schedule		0.08							Fee Schedule											0.1							Fee Schedule		0.08							Fee Schedule		
DEXAMETHASONE 4MG (DECADRON) TABLET	636	RC	J8540	CPT				Both			6.3	2.84	0.02	5.67		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	4.66							Fee Schedule		0.03							Fee Schedule											0.03							Fee Schedule		5.67							Fee Schedule		0.03							Fee Schedule		0.02							Fee Schedule											0.03							Fee Schedule		0.02							Fee Schedule		
DEXON 2-0 7206-51	272	RC						Both			7.35	3.31	3.31	6.62	4.78							Fee Schedule		5.44							Fee Schedule																													6.62							Fee Schedule																																															
DEXON 3-0	272	RC						Both			16.8	7.56	7.56	15.12	10.92							Fee Schedule		12.43							Fee Schedule																													15.12							Fee Schedule																																															
DEXON 4-0 9604-31	272	RC						Both			15.75	7.09	7.09	14.18	10.24							Fee Schedule		11.66							Fee Schedule																													14.18							Fee Schedule																																															
DEXON 5-0 9604-21	272	RC						Both			14.7	6.62	6.62	13.23	9.56							Fee Schedule		10.88							Fee Schedule																													13.23							Fee Schedule																																															
DEXON 6-0 9604-11	272	RC						Both			14.7	6.62	6.62	13.23	9.56							Fee Schedule		10.88							Fee Schedule																													13.23							Fee Schedule																																															
DEXTROMETHORPH POLYSTIREX 30 MG/5ML SUSP	250	RC	A9270	CPT				Both			4.2	1.89	0.01	3.78	0.01							Fee Schedule		3.11							Fee Schedule																													3.78							Fee Schedule																																															
DEXTROSE 25% WATER- 10ML PFS	636	RC	A4216	CPT				Both			11.55	5.2	0.5	10.4		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	8.55							Fee Schedule		0.56							Fee Schedule											0.54							Fee Schedule		10.4							Fee Schedule		0.62							Fee Schedule		0.5							Fee Schedule											0.62							Fee Schedule		0.5							Fee Schedule		
DEXTROSE 50% + AMINOSYN 10% 1000 ML	250	RC						Both			136.5	61.43	61.43	122.85	88.73							Fee Schedule		101.01							Fee Schedule																													122.85							Fee Schedule																																															
DEXTROSE 50% + AMINOSYN 3.5% 1000ML  (L)	250	RC						Both			315	141.75	141.75	283.5	204.75							Fee Schedule		233.1							Fee Schedule																													283.5							Fee Schedule																																															
DEXTROSE 50% + AMINOSYN 3.5% 1000ML  (S)	250	RC						Both			288.75	129.94	129.94	259.88	187.69							Fee Schedule		213.68							Fee Schedule																													259.88							Fee Schedule																																															
DEXTROSE 50% + AMINOSYN 8.5% 1000ML  (S)	250	RC						Both			343.35	154.51	154.51	309.02	223.18							Fee Schedule		254.08							Fee Schedule																													309.02							Fee Schedule																																															
DEXTROSE 50% 50ML (ABBOJECT)	250	RC	A9270	CPT				Both			18.9	8.51	0.01	17.01	0.01							Fee Schedule		13.99							Fee Schedule																													17.01							Fee Schedule																																															
DEXTROSE 50% 50ML VIAL	250	RC	A9270	CPT				Both			12.3	5.54	0.01	11.07	0.01							Fee Schedule		9.1							Fee Schedule																													11.07							Fee Schedule																																															
DHEA 19894 DEHYDROEPIANDROSTERONE SERUM	301	RC	82626	CPT				Both			177.45	79.85	22.46	159.71	22.46							Fee Schedule		28.08							Fee Schedule		26.03							Fee Schedule		25.27							Fee Schedule		25.27							Fee Schedule		159.71							Fee Schedule		29.06							Fee Schedule		23.5							Fee Schedule		25.27							Fee Schedule		29.06							Fee Schedule		23.5							Fee Schedule		
DHEA S 402 DEHYDROEPIANDROSTERONE SERUM	301	RC	82626	CPT				Both			177.45	79.85	22.46	159.71	22.46							Fee Schedule		28.08							Fee Schedule		26.03							Fee Schedule		25.27							Fee Schedule		25.27							Fee Schedule		159.71							Fee Schedule		29.06							Fee Schedule		23.5							Fee Schedule		25.27							Fee Schedule		29.06							Fee Schedule		23.5							Fee Schedule		
DIABETES TYPE 1 AB PNL 13621	302	RC	86337	CPT				Both			234	105.3	19.03	210.6	19.03							Fee Schedule		23.79							Fee Schedule		22.05							Fee Schedule		21.41							Fee Schedule		21.41							Fee Schedule		210.6							Fee Schedule		24.62							Fee Schedule		19.91							Fee Schedule		21.41							Fee Schedule		24.62							Fee Schedule		19.91							Fee Schedule		
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH MCC"					280	DRG		Inpatient			27514.4	12381.48	12381.48	12381.48							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period							0		No services provided during 15 month lookback period				7426.89	7426.89	7426.89	1 through 10									0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period	
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH CC"					281	DRG		Inpatient			22394.28	10077.43	10077.43	10077.43							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period	
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITHOUT CC/MCC"					282	DRG		Inpatient			17946.13	8075.76	8075.76	8075.76							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback				6975.97	6975.97	6975.97	1 through 10									0		No services provided during 15 month lookback period	
DIABETIC INSOLE LARGE 79-81527	274	RC						Both			124	55.8	55.8	111.6		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	91.76							Fee Schedule																													111.6							Fee Schedule																																															
DIABETIC INSOLE MED 79-81525	274	RC						Both			124	55.8	55.8	111.6		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	91.76							Fee Schedule																													111.6							Fee Schedule																																															
DIABETIC INSOLE XL  79-81528	274	RC						Both			124	55.8	55.8	111.6		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	91.76							Fee Schedule																													111.6							Fee Schedule																																															
DIALYSIS CATH. 12.5X17  5533620 ( BARD P	278	RC	C1750	CPT				Both			601.65	270.74	270.74	541.49		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	445.22							Fee Schedule																													541.49							Fee Schedule																																															
DIALYSIS CATH. 14.5FR  5396190 (BARD PV)	278	RC	C1750	CPT				Both			1251	562.95	562.95	1125.9		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	925.74							Fee Schedule																													1125.9							Fee Schedule																																															
DIALYSIS CATH. 14.5FR  5835190 (BARD PV)	278	RC	C1750	CPT				Both			1212.75	545.74	545.74	1091.48		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	897.44							Fee Schedule																													1091.48							Fee Schedule																																															
DIALYSIS CATH. 16FR  5885150 (BARD PV)	278	RC	C1750	CPT				Both			1203	541.35	541.35	1082.7		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	890.22							Fee Schedule																													1082.7							Fee Schedule																																															
DIALYSIS CATH. 19FR  5533690 ( BARD P	278	RC	C1750	CPT				Both			601.65	270.74	270.74	541.49		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	445.22							Fee Schedule																													541.49							Fee Schedule																																															
DIALYSIS CATH. 8811313015	278	RC	C1750	CPT				Both			478	215.1	215.1	430.2		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	353.72							Fee Schedule																													430.2							Fee Schedule																																															
DIAPER RASH PASTE(DESITIN)-4OZ	250	RC	A9270	CPT				Both			17.94	8.07	0.01	16.15	0.01							Fee Schedule		13.28							Fee Schedule																													16.15							Fee Schedule																																															
DIAPER RASH PASTE-1 OZ	250	RC	A9270	CPT				Both			8.25	3.71	0.01	7.43	0.01							Fee Schedule		6.11							Fee Schedule																													7.43							Fee Schedule																																															
DIAPER RASH PASTE-2 OZ	250	RC	A9270	CPT				Both			8.4	3.78	0.01	7.56	0.01							Fee Schedule		6.22							Fee Schedule																													7.56							Fee Schedule																																															
DIAPHRAGM SIZE 7   # MXWF70 COOPER SURGI	272	RC	A4266	CPT				Both			186.11	83.75	27.69	167.5	27.69							Fee Schedule		137.72							Fee Schedule																													167.5							Fee Schedule																																															
DIASTAT 5 MG PED RECTAL GEL	250	RC	A9270	CPT				Both			373.8	168.21	0.01	336.42	0.01							Fee Schedule		276.61							Fee Schedule																													336.42							Fee Schedule																																															
DIAZEPAM  VALIUM  90853 SERUM	301	RC	80307	CPT				Both			111.3	50.09	50.09	100.17	51.72							Fee Schedule		64.65							Fee Schedule		64							Fee Schedule		62.14							Fee Schedule		62.14							Fee Schedule		100.17							Fee Schedule		71.46							Fee Schedule		57.79							Fee Schedule		62.14							Fee Schedule		71.46							Fee Schedule		57.79							Fee Schedule		
DIAZEPAM (DIASTAT) 2.5 MG PED RECTAL GEL	250	RC	A9270	CPT				Both			373.8	168.21	0.01	336.42	0.01							Fee Schedule		276.61							Fee Schedule																													336.42							Fee Schedule																																															
DIAZEPAM 10MG/2ML (VALIUM) SYRINGE	636	RC	J3360	CPT				Both			94.5	42.53	1.6	85.05		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	69.93							Fee Schedule		7.06							Fee Schedule		1.6							Fee Schedule		6.85							Fee Schedule		85.05							Fee Schedule		7.88							Fee Schedule		6.37							Fee Schedule											7.88							Fee Schedule		6.37							Fee Schedule		
DIAZEPAM 2 MG (VALIUM) TABLET	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
DIAZEPAM 5 MG (VALIUM) TABLET	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
DIAZEPAM 50MG/10ML (VALIUM) 10ML VIAL	636	RC	J3360	CPT				Both			14.37	6.47	1.6	12.93		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	10.63							Fee Schedule		7.06							Fee Schedule		1.6							Fee Schedule		6.85							Fee Schedule		12.93							Fee Schedule		7.88							Fee Schedule		6.37							Fee Schedule											7.88							Fee Schedule		6.37							Fee Schedule		
DIAZEPAM INJECTION SOLUTION 5MG/1ML	250	RC	J3360	CPT				Both			12.6	5.67	1.6	11.34	9.42							Fee Schedule		9.32							Fee Schedule		7.06							Fee Schedule		1.6							Fee Schedule		6.85							Fee Schedule		11.34							Fee Schedule		7.88							Fee Schedule		6.37							Fee Schedule											7.88							Fee Schedule		6.37							Fee Schedule		
DIBUCAINE 1% OINTMENT- 30GM	250	RC	A9270	CPT				Both			10.99	4.95	0.01	9.89	0.01							Fee Schedule		8.13							Fee Schedule																													9.89							Fee Schedule																																															
DIBUCAINE 7961 SERUM	301	RC	82638	CPT				Both			68.25	30.71	10.89	61.43	10.89							Fee Schedule		13.61							Fee Schedule		12.62							Fee Schedule		12.25							Fee Schedule		12.25							Fee Schedule		61.43							Fee Schedule		14.09							Fee Schedule		11.39							Fee Schedule		12.25							Fee Schedule		14.09							Fee Schedule		11.39							Fee Schedule		
DICLOFENAC 1% TOP GEL-50GM	250	RC	A9270	CPT				Both			24.48	11.02	0.01	22.03	0.01							Fee Schedule		18.12							Fee Schedule																													22.03							Fee Schedule																																															
DICLOFENAC 50MG TABLET UD	250	RC	A9270	CPT				Both			4.2	1.89	0.01	3.78	0.01							Fee Schedule		3.11							Fee Schedule																													3.78							Fee Schedule																																															
DICLOFENAC 75 MG (VOLTAREN)  TABLET UD	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
DICLOXACILLIN 250 MG CAPSULE UD	250	RC	A9270	CPT				Both			5.25	2.36	0.01	4.73	0.01							Fee Schedule		3.89							Fee Schedule																													4.73							Fee Schedule																																															
DICYCLOMINE 10 MG/ML-2ML (BENTYL) INJ	636	RC	J0500	CPT				Both			153.3	68.99	3.51	137.97		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	113.44							Fee Schedule		8.78							Fee Schedule		3.51							Fee Schedule		8.52							Fee Schedule		137.97							Fee Schedule		9.8							Fee Schedule		7.92							Fee Schedule											9.8							Fee Schedule		7.92							Fee Schedule		
DICYCLOMINE 10MG (BENTYL) CAPSULE	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
DICYCLOMINE 20MG (BENTYL) TABLET	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
DIDRONEL 200 MG TAB	250	RC	A9270	CPT				Both			5.31	2.39	0.01	4.78	0.01							Fee Schedule		3.93							Fee Schedule																													4.78							Fee Schedule																																															
DIDRONEL 50MG/ML-6ML VIAL	636	RC	J1436	CPT				Both			200.34	90.15	90.15	180.31		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	148.25							Fee Schedule																													180.31							Fee Schedule																																															
DIFFUSION MIXTURE FOR PFT #536050-001	270	RC						Both			677.25	304.76	304.76	609.53	440.21							Fee Schedule		501.17							Fee Schedule																													609.53							Fee Schedule																																															
DIFLUCAN 40MG/ML SUSP-35ML	250	RC	A9270	CPT				Both			101.19	45.54	0.01	91.07	0.01							Fee Schedule		74.88							Fee Schedule																													91.07							Fee Schedule																																															
DIGESTIVE ADVANTAGE	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
"ACUTE MYOCARDIAL INFARCTION, EXPIRED WITH MCC"					283	DRG		Inpatient			34439.01	15497.55	15497.55	15497.55							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period							0		No services provided during 15 month lookback period				11459.96	11459.96	11459.96	1 through 10									0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period	
ACUTE AND SUBACUTE ENDOCARDITIS WITH MCC					288	DRG		Inpatient			26555.36	11949.91	11949.91	11949.91							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period				7348.37	7348.37	7348.37	1 through 10									0		No services provided during 15 month lookback							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period	
DIGIFAB  (DIGOXIN IMMUNE FAB) 40 MG VIAL	636	RC	J1162	CPT				Both			13650	6142.5	4805.3	12285		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	5166.99							Fee Schedule		5322							Fee Schedule											5166.99							Fee Schedule		12285							Fee Schedule		5942.04							Fee Schedule		4805.3							Fee Schedule											5942.04							Fee Schedule		4805.3							Fee Schedule		
DIGIFAB (DIGOXIN IMMUNE FAB) 40 MG VIAL	250	RC	J1162	CPT				Both			2604	1171.8	1171.8	5942.04	3780.19							Fee Schedule		5166.99							Fee Schedule		5322							Fee Schedule											5166.99							Fee Schedule		2343.6							Fee Schedule		5942.04							Fee Schedule		4805.3							Fee Schedule											5942.04							Fee Schedule		4805.3							Fee Schedule		
DIGOXIN 0.05 MG CAPSULE UD	250	RC	A9270	CPT				Both			4.2	1.89	0.01	3.78	0.01							Fee Schedule		3.11							Fee Schedule																													3.78							Fee Schedule																																															
DIGOXIN 0.05MG/ML (LaNOXin) SOL-60ML	250	RC	A9270	CPT				Both			504	226.8	0.01	453.6	0.01							Fee Schedule		372.96							Fee Schedule																													453.6							Fee Schedule																																															
DIGOXIN 0.1 MG CAPSULE UD	250	RC	A9270	CPT				Both			5.25	2.36	0.01	4.73	0.01							Fee Schedule		3.89							Fee Schedule																													4.73							Fee Schedule																																															
DIGOXIN 0.125 MG (LANOXIN) TABLET	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
DIGOXIN 0.25 MG (LANOXIN) TABLET	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
DIGOXIN 0.25MG/ 5ML (LaNOXin) SOL-UD	250	RC	A9270	CPT				Both			50.01	22.5	0.01	45.01	0.01							Fee Schedule		37.01							Fee Schedule																													45.01							Fee Schedule																																															
DIGOXIN 0.5 MG/2ML (LaNOXin) INJECTION	636	RC	J1160	CPT				Both			6.3	2.84	1.4	5.67		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	4.66							Fee Schedule		4.03							Fee Schedule		1.4							Fee Schedule		3.91							Fee Schedule		5.67							Fee Schedule		4.5							Fee Schedule		3.64							Fee Schedule											4.5							Fee Schedule		3.64							Fee Schedule		
DIGOXIN LANOXIN	301	RC	80162	CPT				Both			133.35	60.01	11.8	120.02	11.8							Fee Schedule		14.75							Fee Schedule		13.68							Fee Schedule		13.28							Fee Schedule		13.28							Fee Schedule		120.02							Fee Schedule		15.27							Fee Schedule		12.35							Fee Schedule		13.28							Fee Schedule		15.27							Fee Schedule		12.35							Fee Schedule		
DIHYDROERGOTAMINE - 1 MG/ML INJECTION	636	RC	J1110	CPT				Both			142.8	64.26	13.74	128.52		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	105.67							Fee Schedule		56.63							Fee Schedule		13.74							Fee Schedule		54.98							Fee Schedule		128.52							Fee Schedule		63.22							Fee Schedule		51.13							Fee Schedule											63.22							Fee Schedule		51.13							Fee Schedule		
DIHYDROTESTOSTERONE DHT 90567	301	RC	82642	CPT				Both			124.95	56.23	21.04	112.46	21.04							Fee Schedule		32.53							Fee Schedule		30.16							Fee Schedule		29.28							Fee Schedule		29.28							Fee Schedule		112.46							Fee Schedule		33.67							Fee Schedule		27.23							Fee Schedule		29.28							Fee Schedule		33.67							Fee Schedule		27.23							Fee Schedule		
DILANTIN  50 MG (PHENYTOIN) CHEW TABLET	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
DILANTIN PHENYTOIN	301	RC	80185	CPT				Both			149.1	67.1	11.78	134.19	11.78							Fee Schedule		14.73							Fee Schedule		13.65							Fee Schedule		13.25							Fee Schedule		13.25							Fee Schedule		134.19							Fee Schedule		15.24							Fee Schedule		12.32							Fee Schedule		13.25							Fee Schedule		15.24							Fee Schedule		12.32							Fee Schedule		
DILATOR 48 FR SGD167	272	RC						Both			759.15	341.62	341.62	683.24	493.45							Fee Schedule		561.77							Fee Schedule																													683.24							Fee Schedule																																															
DILATOR 51 FR SGD177	272	RC						Both			759.15	341.62	341.62	683.24	493.45							Fee Schedule		561.77							Fee Schedule																													683.24							Fee Schedule																																															
DILAUDID 0.5MG/0.5ML INJECTABLE	250	RC	J1171	CPT				Both			14.94	6.72	0.13	13.45	9.71							Fee Schedule		11.06							Fee Schedule		0.14							Fee Schedule											0.14							Fee Schedule		13.45							Fee Schedule		0.16							Fee Schedule		0.13							Fee Schedule											0.16							Fee Schedule		0.13							Fee Schedule		
DILAUDID 2 MG/ML (HYDROmorphone) INJECTI	636	RC	J1171	CPT				Both			12.6	5.67	0.13	11.34		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	9.32							Fee Schedule		0.14							Fee Schedule											0.14							Fee Schedule		11.34							Fee Schedule		0.16							Fee Schedule		0.13							Fee Schedule											0.16							Fee Schedule		0.13							Fee Schedule		
DILAUDID 50 MG/ML(HP) VIAL (PCA)	636	RC	J1170	CPT				Both			52.5	23.63	23.63	47.25		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	38.85							Fee Schedule																													47.25							Fee Schedule																																															
DILTIAZEM 100 MG ADDV VIAL	250	RC	J3490	CPT				Both			41.07	18.48	18.48	36.96	26.7							Fee Schedule		30.39							Fee Schedule																													36.96							Fee Schedule																																															
DILTIAZEM 100 MG/100 ML-PREMIX	250	RC	J3490	CPT				Both			138.39	62.28	62.28	124.55	89.95							Fee Schedule		102.41							Fee Schedule																													124.55							Fee Schedule																																															
DILTIAZEM 125 MG/ D5W 125 ML-QUVA	250	RC	J3490	CPT				Both			77.4	34.83	34.83	69.66	50.31							Fee Schedule		57.28							Fee Schedule																													69.66							Fee Schedule																																															
DILTIAZEM 125 MG/NS 125 ML IVPB	250	RC						Both			35.44	15.95	15.95	31.9	23.04							Fee Schedule		26.23							Fee Schedule																													31.9							Fee Schedule																																															
DILTIAZEM 25MG/5ML VIAL	250	RC	J3490	CPT				Both			12.6	5.67	5.67	11.34	8.19							Fee Schedule		9.32							Fee Schedule																													11.34							Fee Schedule																																															
DILTIAZEM 30MG (CARDIZEM) TABLET	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
DILTIAZEM CD 120MG (CARDIZEM) CAPSULE	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
DILTIAZEM CD 180MG (CARDIZEM) CAPSULE	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
DILTIAZEM CD 240MG (CARDIZEM) CAPSULE	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
DILTIAZEM CD 300MG (CARDIZEM) CAPSULE	250	RC	A9270	CPT				Both			8.4	3.78	0.01	7.56	0.01							Fee Schedule		6.22							Fee Schedule																													7.56							Fee Schedule																																															
DIMAPHEN ELIXIR (DIMETAPP) 4 OZ	250	RC	A9270	CPT				Both			7.94	3.57	0.01	7.15	0.01							Fee Schedule		5.88							Fee Schedule																													7.15							Fee Schedule																																															
DIMETANE 2 MG/5ML ELIXIR UD	250	RC	A9270	CPT				Both			4.2	1.89	0.01	3.78	0.01							Fee Schedule		3.11							Fee Schedule																													3.78							Fee Schedule																																															
DIPHEN/LID/SUCRAL/MYLANTA -120ML BOTTLE	250	RC	A9270	CPT				Both			187.95	84.58	0.01	169.16	0.01							Fee Schedule		139.08							Fee Schedule																													169.16							Fee Schedule																																															
DIPHENHYDRAMINE 12.5 MG/5ML LIQUID UD	250	RC	Q0163	CPT				Both			6.3	2.84	0.03	5.67	0.03							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
DIPHENHYDRAMINE 12.5MG/5ML LIQUID UD	250	RC	Q0163	CPT				Both			10.5	4.73	0.03	9.45	0.03							Fee Schedule		7.77							Fee Schedule																													9.45							Fee Schedule																																															
DIPHENHYDRAMINE 12.5MG/5ML LIQUID-118ML	250	RC	Q0163	CPT				Both			14.37	6.47	0.03	12.93	0.03							Fee Schedule		10.63							Fee Schedule																													12.93							Fee Schedule																																															
DIPHENHYDRAMINE 25MG (BENADRYL)	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
DIPHENHYDRAMINE 50 MG/ML (BENADRYL) INJ	636	RC	J1200	CPT				Both			12.6	5.67	0.7	11.34		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	9.32							Fee Schedule		0.77							Fee Schedule		0.9							Fee Schedule		0.75							Fee Schedule		11.34							Fee Schedule		0.86							Fee Schedule		0.7							Fee Schedule											0.86							Fee Schedule		0.7							Fee Schedule		
DIPHENHYDRAMINE 50MG (BENADRYL) CAPSULE	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
DIPHENOXLATE/ ATROPINE (LOMOTIL)-5ML UD	250	RC	A9270	CPT				Both			22.05	9.92	0.01	19.85	0.01							Fee Schedule		16.32							Fee Schedule																													19.85							Fee Schedule																																															
DIPHENOXYLATE /ATROPINE (LOMOTIL) TABLET	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
DIPHTHERIA ANTIBODIES 4865 1ML SERUM	302	RC	86648	CPT				Both			200.55	90.25	13.51	180.5	13.51							Fee Schedule		16.9							Fee Schedule		15.67							Fee Schedule		15.21							Fee Schedule		15.21							Fee Schedule		180.5							Fee Schedule		17.49							Fee Schedule		14.15							Fee Schedule		15.21							Fee Schedule		17.49							Fee Schedule		14.15							Fee Schedule		
DIPIVEFRIN 0.1% OPTH SOLUTIO - 5ML	250	RC	A9270	CPT				Both			44.29	19.93	0.01	39.86	0.01							Fee Schedule		32.77							Fee Schedule																													39.86							Fee Schedule																																															
DIPROLENE OINT .05%-45GM	250	RC	A9270	CPT				Both			103.07	46.38	0.01	92.76	0.01							Fee Schedule		76.27							Fee Schedule																													92.76							Fee Schedule																																															
DIPYRIDAMOLE 25 MG TABLET	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
DIPYRIDAMOLE 5 MG/ML- 2ML VIAL	636	RC	J1245	CPT				Both			107.1	48.2	7.82	96.39		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	79.25							Fee Schedule		8.66							Fee Schedule		38.15							Fee Schedule		8.41							Fee Schedule		96.39							Fee Schedule		9.67							Fee Schedule		7.82							Fee Schedule											9.67							Fee Schedule		7.82							Fee Schedule		
DIPYRIDAMOLE 50 MG TABLET UD	250	RC	A9270	CPT				Both			5.25	2.36	0.01	4.73	0.01							Fee Schedule		3.89							Fee Schedule																													4.73							Fee Schedule																																															
DISOPYRAMIDE 100 MG CAPSULE UD	250	RC	A9270	CPT				Both			4.2	1.89	0.01	3.78	0.01							Fee Schedule		3.11							Fee Schedule																													3.78							Fee Schedule																																															
DISOPYRAMIDE 416 SERUM	301	RC	80299	CPT				Both			85.05	38.27	13.42	76.55	13.42							Fee Schedule		18.64							Fee Schedule		19.2							Fee Schedule		18.64							Fee Schedule		18.64							Fee Schedule		76.55							Fee Schedule		21.44							Fee Schedule		17.34							Fee Schedule		18.64							Fee Schedule		21.44							Fee Schedule		17.34							Fee Schedule		
DISOPYRAMIDE CR 150MG CAPSULE UD	250	RC	A9270	CPT				Both			1.58	0.71	0.01	1.42	0.01							Fee Schedule		1.17							Fee Schedule																													1.42							Fee Schedule																																															
HEART FAILURE AND SHOCK WITH MCC					291	DRG		Inpatient			24760.72	11142.33	11142.33	11142.33							0		No services performed during 15 month lookback period. 				11558.62	7484.35	23682.03	1 through 10						6498.72	6498.72	6498.72	1 through 10						3820.3	3820.3	3820.3	1 through 10						7314.99	5970.48	9617.65	28						9501.81	9501.81	9501.81	1 through 10						12092.47	12092.47	12092.47	1 through 10						4899.4	4899.4	4899.4	1 through 10						3680.54	3680.54	3680.54	1 through 10									0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period	
HEART FAILURE AND SHOCK WITH CC					292	DRG		Inpatient			26710.69	12019.81	12019.81	12019.81							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period. 				8015.18	8015.18	8015.18	1 through 10									0		No services provided during 15 month lookback period				5131.79	5131.79	5131.79	1 through 10									0		No services provided during 15 month lookback period				9172.49	9172.49	9172.49	1 through 10									0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period	
HEART FAILURE AND SHOCK WITHOUT CC/MCC					293	DRG		Inpatient			19598.3	8819.24	8819.24	8819.24							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period	
PERIPHERAL VASCULAR DISORDERS WITH CC					300	DRG		Inpatient			28916.35	13012.36	13012.36	13012.36							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period							0		No services provided during 15 month lookback period				6463.69	6463.69	6463.69	1 through 10									0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period	
PERIPHERAL VASCULAR DISORDERS WITHOUT CC/MCC					301	DRG		Inpatient			29714.61	13371.57	13371.57	13371.57							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period	
HYPERTENSION WITH MCC					304	DRG		Inpatient			17792	8006.4	8006.4	8006.4							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period	
HYPERTENSION WITHOUT MCC					305	DRG		Inpatient			20618.77	9278.45	9278.45	9278.45							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period							0		No services provided during 15 month lookback period				4478.36	4478.36	4478.36	1 through 10									0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback				377.77	377.77	377.77	1 through 10									0		No services provided during 15 month lookback period	
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH MCC					308	DRG		Inpatient			37959.55	17081.8	17081.8	17081.8							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period							0		No services provided during 15 month lookback period				6851.28	6851.28	6851.28	1 through 10									0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback							0		No services provided during 15 month lookback period				1544.56	1544.56	1544.56	1 through 10			
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH CC					309	DRG		Inpatient			21222.56	9550.15	9550.15	9550.15							0		No services performed during 15 month lookback period. 				3891.55	3891.55	3891.55	1 through 10						7440.82	7440.82	7440.82	1 through 10									0		No services provided during 15 month lookback period				3389.79	3389.79	3389.79	1 through 10									0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback				5978.94	5978.94	5978.94	1 through 10									0		No services provided during 15 month lookback period	
DISP ROTH RETR NET	272	RC						Both			143.85	64.73	64.73	129.47	93.5							Fee Schedule		106.45							Fee Schedule																													129.47							Fee Schedule																																															
DISP SIGMOID SCOPE	271	RC						Both			3.15	1.42	1.42	2.84	2.05							Fee Schedule		2.33							Fee Schedule																													2.84							Fee Schedule																																															
DISP SNARE HEX DPN1015	272	RC						Both			54.6	24.57	24.57	49.14	35.49							Fee Schedule		40.4							Fee Schedule																													49.14							Fee Schedule																																															
DISP SNARE LGOV DPOL101	272	RC						Both			54.6	24.57	24.57	49.14	35.49							Fee Schedule		40.4							Fee Schedule																													49.14							Fee Schedule																																															
DISP SNARE ST DPOS1015	272	RC						Both			54.6	24.57	24.57	49.14	35.49							Fee Schedule		40.4							Fee Schedule																													49.14							Fee Schedule																																															
DISP TOURNIQUET 12  5921-212-235	272	RC						Both			56.7	25.52	25.52	51.03	36.86							Fee Schedule		41.96							Fee Schedule																													51.03							Fee Schedule																																															
DISP TOURNIQUET 18  5921-218-235	272	RC						Both			30	13.5	13.5	27	19.5							Fee Schedule		22.2							Fee Schedule																													27							Fee Schedule																																															
DISP TOURNIQUET 24  5921-024-235	272	RC						Both			65	29.25	29.25	58.5	42.25							Fee Schedule		48.1							Fee Schedule																													58.5							Fee Schedule																																															
DISP TOURNIQUET 30  5921-030-235	272	RC						Both			97.65	43.94	43.94	87.89	63.47							Fee Schedule		72.26							Fee Schedule																													87.89							Fee Schedule																																															
DISP TOURNIQUET 34  5921-034-235  SUSTAI	272	RC						Both			75	33.75	33.75	67.5	48.75							Fee Schedule		55.5							Fee Schedule																													67.5							Fee Schedule																																															
DISP VARE INJ LDV123	272	RC						Both			101.85	45.83	45.83	91.67	66.2							Fee Schedule		75.37							Fee Schedule																													91.67							Fee Schedule																																															
DISP. HOYER LIFT SLING	270	RC						Both			80	36	36	72	52							Fee Schedule		59.2							Fee Schedule																													72							Fee Schedule																																															
DISP. ORTHOPEDIC SHORTS 2XL-4XL *DISC.*	271	RC						Both			5.25	2.36	2.36	4.73	3.41							Fee Schedule		3.89							Fee Schedule																													4.73							Fee Schedule																																															
DISP. ORTHOPEDIC SHORTS 2XLARGE	270	RC						Both			4	1.8	1.8	3.6	2.6							Fee Schedule		2.96							Fee Schedule																													3.6							Fee Schedule																																															
DISP. ORTHOPEDIC SHORTS LARGE	270	RC						Both			2.1	0.95	0.95	1.89	1.37							Fee Schedule		1.55							Fee Schedule																													1.89							Fee Schedule																																															
DISP. ORTHOPEDIC SHORTS XLARGE	270	RC						Both			4	1.8	1.8	3.6	2.6							Fee Schedule		2.96							Fee Schedule																													3.6							Fee Schedule																																															
DISP. PROBE GUIDE FORK SHAPE 8G MG08A	272	RC						Both			76	34.2	34.2	68.4	49.4							Fee Schedule		56.24							Fee Schedule																													68.4							Fee Schedule																																															
DISP. SKIN STAPLER #054873	272	RC						Both			28.35	12.76	12.76	25.52	18.43							Fee Schedule		20.98							Fee Schedule																													25.52							Fee Schedule																																															
DISP.BLOOD PRESSUE CUFF W/BULB ADULT	270	RC	A4663	CPT				Both			27.3	12.29	12.29	24.57	13.23							Fee Schedule		20.2							Fee Schedule																													24.57							Fee Schedule																																															
DISPERMOX 200 MG TABLET FOR ORAL SUSP	250	RC	A9270	CPT				Both			4.2	1.89	0.01	3.78	0.01							Fee Schedule		3.11							Fee Schedule																													3.78							Fee Schedule																																															
DISPOSABLE BABCOCK GRASPER 10MM DIAMETER	272	RC						Both			431.55	194.2	194.2	388.4	280.51							Fee Schedule		319.35							Fee Schedule																													388.4							Fee Schedule																																															
DISPOSABLE BIOPSY FORCEP FB-220U	272	RC						Both			19.95	8.98	8.98	17.96	12.97							Fee Schedule		14.76							Fee Schedule																													17.96							Fee Schedule																																															
DISPOSABLE BOVIE NEEDLE #ES02	272	RC						Both			8	3.6	3.6	7.2	5.2							Fee Schedule		5.92							Fee Schedule																													7.2							Fee Schedule																																															
DISPOSABLE CAUTERY ER	272	RC						Both			18.9	8.51	8.51	17.01	12.29							Fee Schedule		13.99							Fee Schedule																													17.01							Fee Schedule																																															
DISPOSABLE FORCEP BARD USER CHG.	272	RC						Both			28.35	12.76	12.76	25.52	18.43							Fee Schedule		20.98							Fee Schedule																													25.52							Fee Schedule																																															
DISPOSABLE FORCEP WILSON COOK	272	RC						Both			657.3	295.79	295.79	591.57	427.25							Fee Schedule		486.4							Fee Schedule																													591.57							Fee Schedule																																															
DISPOSABLE HYPO PAD DHP901	270	RC						Both			48.3	21.74	21.74	43.47	31.4							Fee Schedule		35.74							Fee Schedule																													43.47							Fee Schedule																																															
DISTAL COVER SINGLE USE MAJ-2315	272	RC						Both			20	9	9	18	13							Fee Schedule		14.8							Fee Schedule																													18							Fee Schedule																																															
DISTAL RADIUS PLATE RIGHT #A-4750.106	278	RC	C1713	CPT				Both			3945	1775.25	1775.25	3550.5		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	2919.3							Fee Schedule																													3550.5							Fee Schedule																																															
DISTAL RADIUS PLATE WRIST RT A-4750.108	278	RC	C1713	CPT				Both			4446	2000.7	2000.7	4001.4		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	3290.04							Fee Schedule																													4001.4							Fee Schedule																																															
DISTAL RADIUS PLATE WRIST RT A-4750.111	278	RC	C1713	CPT				Both			4446	2000.7	2000.7	4001.4		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	3290.04							Fee Schedule																													4001.4							Fee Schedule																																															
DISTAL RADIUS PLATE WRIST STR A-4750.193	278	RC	C1713	CPT				Both			9519	4283.55	4283.55	8567.1		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	7044.06							Fee Schedule																													8567.1							Fee Schedule																																															
DISTAL RADIUS SYSTEM WRIST A-4750-107	278	RC	C1713	CPT				Both			4446	2000.7	2000.7	4001.4		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	3290.04							Fee Schedule																													4001.4							Fee Schedule																																															
DISTAL SPACER	278	RC						Both			269.85	121.43	121.43	242.87		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	199.69							Fee Schedule																													242.87							Fee Schedule																																															
DISTAL TIP	278	RC	C1776	CPT				Both			1146.6	515.97	515.97	1031.94		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	848.48							Fee Schedule																													1031.94							Fee Schedule																																															
DIVALPROEX 250MG (DEPAKOTE) DR TAB	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
DIVALPROEX 250MG EXTENDED RELEASE TABLET	250	RC	A9270	CPT				Both			7.35	3.31	0.01	6.62	0.01							Fee Schedule		5.44							Fee Schedule																													6.62							Fee Schedule																																															
DIVALPROEX SOD 125 MG(DEPAKOTE) SPRINKLE	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
DLCO	460	RC	94729	CPT				Both			283.5	127.58	35.3	318	200							Per Diem		209.79							Fee Schedule											35.3							Fee Schedule											255.15							Fee Schedule																				318							Per Diem																				
"DNA AB, CRITHIDIA REFLX TO TITER 37092"	302	RC	86255	CPT				Both			33.09	14.89	10.71	29.78	10.71							Fee Schedule		13.39							Fee Schedule		12.41							Fee Schedule		12.05							Fee Schedule		12.05							Fee Schedule		29.78							Fee Schedule		13.86							Fee Schedule		11.21							Fee Schedule		12.05							Fee Schedule		13.86							Fee Schedule		11.21							Fee Schedule		
DNA DOUBLE STRAND ANTIBODY 255 SERUM	302	RC	86225	CPT				Both			62	27.9	12.22	55.8	12.22							Fee Schedule		15.27							Fee Schedule		14.15							Fee Schedule		13.74							Fee Schedule		13.74							Fee Schedule		55.8							Fee Schedule		15.8							Fee Schedule		12.78							Fee Schedule		13.74							Fee Schedule		15.8							Fee Schedule		12.78							Fee Schedule		
DNASE - B ANTIBODY 256	302	RC	86215	CPT				Both			0.3	0.14	0.14	15.24	11.77							Fee Schedule		14.72							Fee Schedule		13.65							Fee Schedule		13.25							Fee Schedule		13.25							Fee Schedule		0.27							Fee Schedule		15.24							Fee Schedule		12.32							Fee Schedule											15.24							Fee Schedule		12.32							Fee Schedule		
DOB HOFF TUBE	272	RC						Both			63	28.35	28.35	56.7	40.95							Fee Schedule		46.62							Fee Schedule																													56.7							Fee Schedule																																															
DOBB HOFF (ROSS)	272	RC	B4081	CPT				Both			33.6	15.12	8.26	30.24	8.26							Fee Schedule		24.86							Fee Schedule											25.63							Fee Schedule											30.24							Fee Schedule																																															
DOBUTamine 250 MG/20ML VIAL	636	RC	J1250	CPT				Both			21	9.45	7.15	41.25		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	15.54							Fee Schedule		7.92							Fee Schedule		41.25							Fee Schedule		7.69							Fee Schedule		18.9							Fee Schedule		8.84							Fee Schedule		7.15							Fee Schedule											8.84							Fee Schedule		7.15							Fee Schedule		
DOBUTamine 250 MG/250ML PREMIX IVPB	636	RC	J1250	CPT				Both			72.45	32.6	7.15	65.21		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	53.61							Fee Schedule		7.92							Fee Schedule		41.25							Fee Schedule		7.69							Fee Schedule		65.21							Fee Schedule		8.84							Fee Schedule		7.15							Fee Schedule											8.84							Fee Schedule		7.15							Fee Schedule		
DOCUSATE CALCIUM 240MG (SURFAK) CAPSULE	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
DOCUSATE SOD 100 MG/10ML (COLACE) LIQ	250	RC	A9270	CPT				Both			5.25	2.36	0.01	4.73	0.01							Fee Schedule		3.89							Fee Schedule																													4.73							Fee Schedule																																															
DOCUSATE SODIUM 100MG (COLACE) SOFTGEL	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
DOCUSATE SODIUM 100MG/10ML-UD	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
DOLPHIN COLLECTION KIT #006775-901(OLYM)	272	RC						Both			81.9	36.86	36.86	73.71	53.24							Fee Schedule		60.61							Fee Schedule																													73.71							Fee Schedule																																															
DOLPHIN TRANSDUCER TUBING #DOL-TUB(OLYMP	272	RC						Both			280.35	126.16	126.16	252.32	182.23							Fee Schedule		207.46							Fee Schedule																													252.32							Fee Schedule																																															
DOMEBORO ASTRINGENT SOLUTION PACKETS	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
DOMEBORO OTIC SOLUT	250	RC	A9270	CPT				Both			45.71	20.57	0.01	41.14	0.01							Fee Schedule		33.83							Fee Schedule																													41.14							Fee Schedule																																															
DONEPEZIL 10MG TABLET UD	250	RC	A9270	CPT				Both			16.01	7.2	0.01	14.41	0.01							Fee Schedule		11.85							Fee Schedule																													14.41							Fee Schedule																																															
DONJOY SHOULDER LG 11-0449-4-06000L	274	RC	L1832	CPT				Both			143	64.35	64.35	1071.24		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	105.82							Fee Schedule		959.46							Fee Schedule		580.58							Fee Schedule		931.51							Fee Schedule		128.7							Fee Schedule		1071.24							Fee Schedule		866.3							Fee Schedule											1071.24							Fee Schedule		866.3							Fee Schedule		
DONJOY SHOULDER SM 0138-2-13130	274	RC	L1832	CPT				Both			143	64.35	64.35	1071.24		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	105.82							Fee Schedule		959.46							Fee Schedule		580.58							Fee Schedule		931.51							Fee Schedule		128.7							Fee Schedule		1071.24							Fee Schedule		866.3							Fee Schedule											1071.24							Fee Schedule		866.3							Fee Schedule		
DONJOY SHOULDER UNIV. (DEROYAL)	274	RC						Both			163	73.35	73.35	146.7		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	120.62							Fee Schedule																													146.7							Fee Schedule																																															
DONNATAL EXTENTAB UD	250	RC	A9270	CPT				Both			4.2	1.89	0.01	3.78	0.01							Fee Schedule		3.11							Fee Schedule																													3.78							Fee Schedule																																															
DONNATAL TABLET UD	250	RC	A9270	CPT				Both			5.25	2.36	0.01	4.73	0.01							Fee Schedule		3.89							Fee Schedule																													4.73							Fee Schedule																																															
DONT USE FLU SHOT (PEDIATRIC)	636	RC	90658	CPT				Both			48.3	21.74	14.28	43.47		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	35.74							Fee Schedule		22.73							Fee Schedule		14.28							Fee Schedule		22.07							Fee Schedule		43.47							Fee Schedule		25.38							Fee Schedule		20.52							Fee Schedule											25.38							Fee Schedule		20.52							Fee Schedule		
DOPamine 400 MG/10ML VIAL	250	RC	J1265	CPT				Both			12.6	5.67	0.72	11.34	0.72							Fee Schedule		9.32							Fee Schedule		1.04							Fee Schedule											1.01							Fee Schedule		11.34							Fee Schedule		1.16							Fee Schedule		0.94							Fee Schedule											1.16							Fee Schedule		0.94							Fee Schedule		
DOPamine 400 MG/250 ML PREMIX IVPB	250	RC	J1265	CPT				Both			46.2	20.79	0.72	41.58	0.72							Fee Schedule		34.19							Fee Schedule		1.04							Fee Schedule											1.01							Fee Schedule		41.58							Fee Schedule		1.16							Fee Schedule		0.94							Fee Schedule											1.16							Fee Schedule		0.94							Fee Schedule		
DOPamine 400 MG/250 ML PREMIX-RENAL	250	RC	J1265	CPT				Both			51.13	23.01	0.72	46.02	0.72							Fee Schedule		37.84							Fee Schedule		1.04							Fee Schedule											1.01							Fee Schedule		46.02							Fee Schedule		1.16							Fee Schedule		0.94							Fee Schedule											1.16							Fee Schedule		0.94							Fee Schedule		
DOPAMINE 800 MG/250 ML PREMIX	250	RC	J1265	CPT				Both			71.4	32.13	0.72	64.26	0.72							Fee Schedule		52.84							Fee Schedule		1.04							Fee Schedule											1.01							Fee Schedule		64.26							Fee Schedule		1.16							Fee Schedule		0.94							Fee Schedule											1.16							Fee Schedule		0.94							Fee Schedule		
DOPAMINE PREMIX	258	RC						Both			22.05	9.92	9.92	19.85	14.33							Fee Schedule		16.32							Fee Schedule																													19.85							Fee Schedule																																															
DOPAMINE URINE 14763 URINE 24HR	301	RC	82542	CPT				Both			189	85.05	17.34	170.1	17.34							Fee Schedule		24.09							Fee Schedule		24.81							Fee Schedule		24.09							Fee Schedule		24.09							Fee Schedule		170.1							Fee Schedule		27.7							Fee Schedule		22.4							Fee Schedule		24.09							Fee Schedule		27.7							Fee Schedule		22.4							Fee Schedule		
DORZOLAM/TIMOLOL 22.3/6.8MG/ML OPTH SOL	250	RC	A9270	CPT				Both			386.4	173.88	0.01	347.76	0.01							Fee Schedule		285.94							Fee Schedule																													347.76							Fee Schedule																																															
DORZOLAMIDE (TRUSOPT) 2% OPTH SOL. 10ML	250	RC	A9270	CPT				Both			210	94.5	0.01	189	0.01							Fee Schedule		155.4							Fee Schedule																													189							Fee Schedule																																															
DOTAREM PREFILLED 20ML 368-230013	272	RC	A9575	CPT				Both			87	39.15	0.08	78.3	0.18							Fee Schedule		64.38							Fee Schedule		0.09							Fee Schedule											0.09							Fee Schedule		78.3							Fee Schedule		0.1							Fee Schedule		0.08							Fee Schedule											0.1							Fee Schedule		0.08							Fee Schedule		
DOTAREM VIALS 20ML 234963	272	RC	A9575	CPT				Both			52	23.4	0.08	46.8	0.18							Fee Schedule		38.48							Fee Schedule		0.09							Fee Schedule											0.09							Fee Schedule		46.8							Fee Schedule		0.1							Fee Schedule		0.08							Fee Schedule											0.1							Fee Schedule		0.08							Fee Schedule		
DOUBLE ARMED MENISCAL REPAIR NEEDLE 8535	272	RC						Both			82.95	37.33	37.33	74.66	53.92							Fee Schedule		61.38							Fee Schedule																													74.66							Fee Schedule																																															
DOUCHE BAG	271	RC						Both			6.3	2.84	2.84	5.67	4.1							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
DOXAPRAM 20 MG/ML- 20 ML MDV (CH/ML)	250	RC	A9270	CPT				Both			54.6	24.57	0.01	49.14	0.01							Fee Schedule		40.4							Fee Schedule																													49.14							Fee Schedule																																															
DOXAZOSIN 1MG (CARDURA) TABLET	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
DOXAZOSIN 4MG (CARDURA) TABLET	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
DOXEPIN  25MG (SINEQUAN) CAPSULE	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
DOXEPIN 10MG (SINEQUAN) CAPSULE	250	RC	A9270	CPT				Both			5.25	2.36	0.01	4.73	0.01							Fee Schedule		3.89							Fee Schedule																													4.73							Fee Schedule																																															
DOXEPIN 10MG CAP	250	RC	A9270	CPT				Both			4.2	1.89	0.01	3.78	0.01							Fee Schedule		3.11							Fee Schedule																													3.78							Fee Schedule																																															
DOXEPIN 150MG (SINEQUAN) CAPSULE	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
DOXEPIN 50 MG CAPSULE UD	250	RC	A9270	CPT				Both			4.2	1.89	0.01	3.78	0.01							Fee Schedule		3.11							Fee Schedule																													3.78							Fee Schedule																																															
DOXEPIN 826 SERUM	301	RC	80307	CPT				Both			74.55	33.55	33.55	71.46	51.72							Fee Schedule		64.65							Fee Schedule		64							Fee Schedule		62.14							Fee Schedule		62.14							Fee Schedule		67.1							Fee Schedule		71.46							Fee Schedule		57.79							Fee Schedule		62.14							Fee Schedule		71.46							Fee Schedule		57.79							Fee Schedule		
DOXIDAN CAPSULES	250	RC	A9270	CPT				Both			4.2	1.89	0.01	3.78	0.01							Fee Schedule		3.11							Fee Schedule																													3.78							Fee Schedule																																															
DOXYCYCLINE 100MG VIAL	250	RC	J3490	CPT				Both			90.6	40.77	40.77	81.54	58.89							Fee Schedule		67.04							Fee Schedule																													81.54							Fee Schedule																																															
DOXYCYCLINE 100MG/NS 100ML IVPB	250	RC	J3490	CPT				Both			91.35	41.11	41.11	82.22	59.38							Fee Schedule		67.6							Fee Schedule																													82.22							Fee Schedule																																															
DOXYCYCLINE 35163 SERUM FROZEN	301	RC	80299	CPT				Both			154.35	69.46	13.42	138.92	13.42							Fee Schedule		18.64							Fee Schedule		19.2							Fee Schedule		18.64							Fee Schedule		18.64							Fee Schedule		138.92							Fee Schedule		21.44							Fee Schedule		17.34							Fee Schedule		18.64							Fee Schedule		21.44							Fee Schedule		17.34							Fee Schedule		
DOXYCYCLINE 50 MG/5ML ORAL SYRUP	250	RC	A9270	CPT				Both			9.45	4.25	0.01	8.51	0.01							Fee Schedule		6.99							Fee Schedule																													8.51							Fee Schedule																																															
DOXYCYCLINE HYCLATE 100 MG	250	RC	A9270	CPT				Both			12.6	5.67	0.01	11.34	0.01							Fee Schedule		9.32							Fee Schedule																													11.34							Fee Schedule																																															
DOXYCYCLINE MONOHYDRATE 25MG/5ML-60ML	250	RC	A9270	CPT				Both			71.4	32.13	0.01	64.26	0.01							Fee Schedule		52.84							Fee Schedule																													64.26							Fee Schedule																																															
DOYLE NASAL PKG	271	RC						Both			70.35	31.66	31.66	63.32	45.73							Fee Schedule		52.06							Fee Schedule																													63.32							Fee Schedule																																															
DR. FOG WIPES (MEDLINE) #NONFB100	272	RC						Both			3	1.35	1.35	2.7	1.95							Fee Schedule		2.22							Fee Schedule																													2.7							Fee Schedule																																															
DRAIN SPONGE SOFT WICK 4X4	272	RC						Both			1.05	0.47	0.47	0.95	0.68							Fee Schedule		0.78							Fee Schedule																													0.95							Fee Schedule																																															
DRAINAGE PROTECTOR & CATH PLUG 000076	272	RC						Both			1.05	0.47	0.47	0.95	0.68							Fee Schedule		0.78							Fee Schedule																													0.95							Fee Schedule																																															
DRAMAMINE 50 MG TABS	250	RC	A9270	CPT				Both			4.2	1.89	0.01	3.78	0.01							Fee Schedule		3.11							Fee Schedule																													3.78							Fee Schedule																																															
DRAWTEX 4X4  #00302	272	RC	A6196	CPT				Both			20	9	6.62	18	6.62							Fee Schedule		14.8							Fee Schedule		10.8							Fee Schedule		8.28							Fee Schedule		10.49							Fee Schedule		18							Fee Schedule		12.06							Fee Schedule		9.76							Fee Schedule											12.06							Fee Schedule		9.76							Fee Schedule		
DRAWTEX EDEMA WRAP 4  #00352	270	RC	A6199	CPT				Both			37	16.65	4.76	33.3	4.76							Fee Schedule		27.38							Fee Schedule		7.75							Fee Schedule		5.95							Fee Schedule		7.52							Fee Schedule		33.3							Fee Schedule		8.65							Fee Schedule		6.99							Fee Schedule											8.65							Fee Schedule		6.99							Fee Schedule		
DRESSING RET 1 GL701	270	RC	A6457	CPT				Both			13	5.85	1.02	11.7	1.02							Fee Schedule		9.62							Fee Schedule		1.67							Fee Schedule											1.62							Fee Schedule		11.7							Fee Schedule		1.86							Fee Schedule		1.51							Fee Schedule											1.86							Fee Schedule		1.51							Fee Schedule		
DRESSING RET 10	270	RC	L1820	CPT				Both			31.5	14.18	14.18	171.34	60.01							Fee Schedule		23.31							Fee Schedule		153.46							Fee Schedule		117.67							Fee Schedule		148.99							Fee Schedule		28.35							Fee Schedule		171.34							Fee Schedule		138.56							Fee Schedule											171.34							Fee Schedule		138.56							Fee Schedule		
DRESSING RET 2	270	RC	L1820	CPT				Both			8.4	3.78	3.78	171.34	60.01							Fee Schedule		6.22							Fee Schedule		153.46							Fee Schedule		117.67							Fee Schedule		148.99							Fee Schedule		7.56							Fee Schedule		171.34							Fee Schedule		138.56							Fee Schedule											171.34							Fee Schedule		138.56							Fee Schedule		
DRESSING RET 3	270	RC	L1820	CPT				Both			15.75	7.09	7.09	171.34	60.01							Fee Schedule		11.66							Fee Schedule		153.46							Fee Schedule		117.67							Fee Schedule		148.99							Fee Schedule		14.18							Fee Schedule		171.34							Fee Schedule		138.56							Fee Schedule											171.34							Fee Schedule		138.56							Fee Schedule		
DRESSING RET 4	270	RC	L1820	CPT				Both			5.25	2.36	2.36	171.34	60.01							Fee Schedule		3.89							Fee Schedule		153.46							Fee Schedule		117.67							Fee Schedule		148.99							Fee Schedule		4.73							Fee Schedule		171.34							Fee Schedule		138.56							Fee Schedule											171.34							Fee Schedule		138.56							Fee Schedule		
DRESSING RET 5 GL705	270	RC	L1820	CPT				Both			20.16	9.07	9.07	171.34	60.01							Fee Schedule		14.92							Fee Schedule		153.46							Fee Schedule		117.67							Fee Schedule		148.99							Fee Schedule		18.14							Fee Schedule		171.34							Fee Schedule		138.56							Fee Schedule											171.34							Fee Schedule		138.56							Fee Schedule		
DRESSING RET 6  GL-707	270	RC						Both			31.5	14.18	14.18	28.35	20.48							Fee Schedule		23.31							Fee Schedule																													28.35							Fee Schedule																																															
DRESSING RET 7	270	RC	L1820	CPT				Both			14.7	6.62	6.62	171.34	60.01							Fee Schedule		10.88							Fee Schedule		153.46							Fee Schedule		117.67							Fee Schedule		148.99							Fee Schedule		13.23							Fee Schedule		171.34							Fee Schedule		138.56							Fee Schedule											171.34							Fee Schedule		138.56							Fee Schedule		
DRESSING RET 8	270	RC	L1820	CPT				Both			15.75	7.09	7.09	171.34	60.01							Fee Schedule		11.66							Fee Schedule		153.46							Fee Schedule		117.67							Fee Schedule		148.99							Fee Schedule		14.18							Fee Schedule		171.34							Fee Schedule		138.56							Fee Schedule											171.34							Fee Schedule		138.56							Fee Schedule		
DRESSING RET 9	270	RC	L1820	CPT				Both			15.75	7.09	7.09	171.34	60.01							Fee Schedule		11.66							Fee Schedule		153.46							Fee Schedule		117.67							Fee Schedule		148.99							Fee Schedule		14.18							Fee Schedule		171.34							Fee Schedule		138.56							Fee Schedule											171.34							Fee Schedule		138.56							Fee Schedule		
DRG MONITORING AMP/METH UR 39385	300	RC	80324	CPT				Both			120	54	0.01	108	0.01							Fee Schedule									Other	No Additional Reimbursement 																												108							Fee Schedule																																															
DRILL BIT 2.7 MODB27	272	RC						Both			153.3	68.99	68.99	137.97	99.65							Fee Schedule		113.44							Fee Schedule																													137.97							Fee Schedule																																															
DRILL BIT 3.0 MODB30	272	RC						Both			153.3	68.99	68.99	137.97	99.65							Fee Schedule		113.44							Fee Schedule																													137.97							Fee Schedule																																															
DRONABINOL 2.5 MG (MARINOL) CAPSULE	250	RC	A9270	CPT				Both			16.8	7.56	0.01	15.12	0.01							Fee Schedule		12.43							Fee Schedule																													15.12							Fee Schedule																																															
DROPERIDOL 5 MG/2 ML INJ	636	RC	J1790	CPT				Both			29.94	13.47	4.75	26.95		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	22.16							Fee Schedule		8.37							Fee Schedule		4.75							Fee Schedule		8.12							Fee Schedule		26.95							Fee Schedule		9.34							Fee Schedule		7.56							Fee Schedule											9.34							Fee Schedule		7.56							Fee Schedule		
DROPERIDOL 5MG/2ML VIAL	636	RC	J1790	CPT				Both			26.25	11.81	4.75	23.63		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	19.43							Fee Schedule		8.37							Fee Schedule		4.75							Fee Schedule		8.12							Fee Schedule		23.63							Fee Schedule		9.34							Fee Schedule		7.56							Fee Schedule											9.34							Fee Schedule		7.56							Fee Schedule		
DROXIDOPA 100MG CAP	250	RC	A9270	CPT				Both			110.34	49.65	0.01	99.31	0.01							Fee Schedule		81.65							Fee Schedule																													99.31							Fee Schedule																																															
"DRUG MONITORING AMPHETAMINE , UR 39368"	300	RC	80307	CPT				Both			399	179.55	51.72	359.1	51.72							Fee Schedule		64.65							Fee Schedule		64							Fee Schedule		62.14							Fee Schedule		62.14							Fee Schedule		359.1							Fee Schedule		71.46							Fee Schedule		57.79							Fee Schedule		62.14							Fee Schedule		71.46							Fee Schedule		57.79							Fee Schedule		
DRUG MONITORING ANTIDEPRESSANTS UR 94032	301	RC	80307	CPT				Both			330.33	148.65	51.72	297.3	51.72							Fee Schedule		64.65							Fee Schedule		64							Fee Schedule		62.14							Fee Schedule		62.14							Fee Schedule		297.3							Fee Schedule		71.46							Fee Schedule		57.79							Fee Schedule		62.14							Fee Schedule		71.46							Fee Schedule		57.79							Fee Schedule		
DRUG MONITORING COCAINE W/CON UR 39374	300	RC	80307	CPT				Both			399	179.55	51.72	359.1	51.72							Fee Schedule		64.65							Fee Schedule		64							Fee Schedule		62.14							Fee Schedule		62.14							Fee Schedule		359.1							Fee Schedule		71.46							Fee Schedule		57.79							Fee Schedule		62.14							Fee Schedule		71.46							Fee Schedule		57.79							Fee Schedule		
DRUG MONITORING MARIJUANA W/CON UR 39377	300	RC	80307	CPT				Both			399	179.55	51.72	359.1	51.72							Fee Schedule		64.65							Fee Schedule		64							Fee Schedule		62.14							Fee Schedule		62.14							Fee Schedule		359.1							Fee Schedule		71.46							Fee Schedule		57.79							Fee Schedule		62.14							Fee Schedule		71.46							Fee Schedule		57.79							Fee Schedule		
"DRUG MONITORING PL 1 W/ CONF, URN 39426"	301	RC	80307	CPT				Both			324	145.8	51.72	291.6	51.72							Fee Schedule		64.65							Fee Schedule		64							Fee Schedule		62.14							Fee Schedule		62.14							Fee Schedule		291.6							Fee Schedule		71.46							Fee Schedule		57.79							Fee Schedule		62.14							Fee Schedule		71.46							Fee Schedule		57.79							Fee Schedule		
"DRUG MONITORING PL8 W/CONF, URN 39430"	301	RC	80307	CPT				Both			426	191.7	51.72	383.4	51.72							Fee Schedule		64.65							Fee Schedule		64							Fee Schedule		62.14							Fee Schedule		62.14							Fee Schedule		383.4							Fee Schedule		71.46							Fee Schedule		57.79							Fee Schedule		62.14							Fee Schedule		71.46							Fee Schedule		57.79							Fee Schedule		
"DRUG MONITORING, METH UR 39413"	300	RC	80374	CPT				Both			201.12	90.5	0.01	181.01	0.01							Fee Schedule									Other	No Additional Reimbursement 																												181.01							Fee Schedule																																															
"DRUG MONITORING, METHADONE & CONF 39379"	300	RC	80307	CPT				Both			399	179.55	51.72	359.1	51.72							Fee Schedule		64.65							Fee Schedule		64							Fee Schedule		62.14							Fee Schedule		62.14							Fee Schedule		359.1							Fee Schedule		71.46							Fee Schedule		57.79							Fee Schedule		62.14							Fee Schedule		71.46							Fee Schedule		57.79							Fee Schedule		
DRUG SCREEN COMP 23019 GASTRIC FLUID	301	RC	80307	CPT				Both			145.95	65.68	51.72	131.36	51.72							Fee Schedule		64.65							Fee Schedule		64							Fee Schedule		62.14							Fee Schedule		62.14							Fee Schedule		131.36							Fee Schedule		71.46							Fee Schedule		57.79							Fee Schedule		62.14							Fee Schedule		71.46							Fee Schedule		57.79							Fee Schedule		
DRUG SCREEN ER (MEDICAL PURPOSES ONLY)	300	RC	80307	CPT				Both			173.25	77.96	51.72	155.93	51.72							Fee Schedule		64.65							Fee Schedule		64							Fee Schedule		62.14							Fee Schedule		62.14							Fee Schedule		155.93							Fee Schedule		71.46							Fee Schedule		57.79							Fee Schedule		62.14							Fee Schedule		71.46							Fee Schedule		57.79							Fee Schedule		
DRUG SCREEN HYDROCODONE 15532 10 ML URI	301	RC	80307	CPT				Both			157.5	70.88	51.72	141.75	51.72							Fee Schedule		64.65							Fee Schedule		64							Fee Schedule		62.14							Fee Schedule		62.14							Fee Schedule		141.75							Fee Schedule		71.46							Fee Schedule		57.79							Fee Schedule		62.14							Fee Schedule		71.46							Fee Schedule		57.79							Fee Schedule		
DRUG SCREEN MECONIUM 30427 5 GRAMS FROZ	301	RC	80307	CPT				Both			175.35	78.91	51.72	157.82	51.72							Fee Schedule		64.65							Fee Schedule		64							Fee Schedule		62.14							Fee Schedule		62.14							Fee Schedule		157.82							Fee Schedule		71.46							Fee Schedule		57.79							Fee Schedule		62.14							Fee Schedule		71.46							Fee Schedule		57.79							Fee Schedule		
DRUG SCREEN OXYCODONE 14450 URINE	301	RC	80306	CPT				Both			124.95	56.23	12.93	112.46	12.93							Fee Schedule		17.14							Fee Schedule		17.65							Fee Schedule		17.14							Fee Schedule		17.14							Fee Schedule		112.46							Fee Schedule		19.71							Fee Schedule		15.94							Fee Schedule		17.14							Fee Schedule		19.71							Fee Schedule		15.94							Fee Schedule		
DRUG SCREEN SERUM COCAINE ONLY (26568)	301	RC	80307	CPT				Both			326.55	146.95	51.72	293.9	51.72							Fee Schedule		64.65							Fee Schedule		64							Fee Schedule		62.14							Fee Schedule		62.14							Fee Schedule		293.9							Fee Schedule		71.46							Fee Schedule		57.79							Fee Schedule		62.14							Fee Schedule		71.46							Fee Schedule		57.79							Fee Schedule		
DRUG SCREEN SINGLE EACH	300	RC	80307	CPT				Both			124.95	56.23	51.72	112.46	51.72							Fee Schedule		64.65							Fee Schedule		64							Fee Schedule		62.14							Fee Schedule		62.14							Fee Schedule		112.46							Fee Schedule		71.46							Fee Schedule		57.79							Fee Schedule		62.14							Fee Schedule		71.46							Fee Schedule		57.79							Fee Schedule		
DRUG SCREEN URINE DOT COC 7643N	300	RC	80306	CPT				Both			75.6	34.02	12.93	68.04	12.93							Fee Schedule		17.14							Fee Schedule		17.65							Fee Schedule		17.14							Fee Schedule		17.14							Fee Schedule		68.04							Fee Schedule		19.71							Fee Schedule		15.94							Fee Schedule		17.14							Fee Schedule		19.71							Fee Schedule		15.94							Fee Schedule		
DRUG SCREEN URINE ETHYL ONLY 2128	300	RC	80307	CPT				Both			96.6	43.47	43.47	86.94	51.72							Fee Schedule		64.65							Fee Schedule		64							Fee Schedule		62.14							Fee Schedule		62.14							Fee Schedule		86.94							Fee Schedule		71.46							Fee Schedule		57.79							Fee Schedule		62.14							Fee Schedule		71.46							Fee Schedule		57.79							Fee Schedule		
DRUG SCREEN URINE LSD ONLY 8456	301	RC	80307	CPT				Both			294	132.3	51.72	264.6	51.72							Fee Schedule		64.65							Fee Schedule		64							Fee Schedule		62.14							Fee Schedule		62.14							Fee Schedule		264.6							Fee Schedule		71.46							Fee Schedule		57.79							Fee Schedule		62.14							Fee Schedule		71.46							Fee Schedule		57.79							Fee Schedule		
"DRUG SCREEN, UR AUTOMATED (MEDICAL ONLY)"	301	RC	80307	CPT				Both			260	117	51.72	234	51.72							Fee Schedule		64.65							Fee Schedule		64							Fee Schedule		62.14							Fee Schedule		62.14							Fee Schedule		234							Fee Schedule		71.46							Fee Schedule		57.79							Fee Schedule		62.14							Fee Schedule		71.46							Fee Schedule		57.79							Fee Schedule		
"DRUG TEST, GEN TOX, SERUM 91360"	301	RC	G0483	CPT				Both			406.65	182.99	177.78	365.99	177.78							Fee Schedule		246.92							Fee Schedule		254.33							Fee Schedule		246.92							Fee Schedule		246.92							Fee Schedule		365.99							Fee Schedule		283.96							Fee Schedule		229.64							Fee Schedule		246.92							Fee Schedule		283.96							Fee Schedule		229.64							Fee Schedule		
DRYSOL TOPICAL	250	RC	A9270	CPT				Both			36.75	16.54	0.01	33.08	0.01							Fee Schedule		27.2							Fee Schedule																													33.08							Fee Schedule																																															
DUAL LUMEN KIT SAFETY #CDC-21242-1A  ARO	272	RC	A4300	CPT				Both			420	189	4.57	378	17.2							Fee Schedule		310.8							Fee Schedule											4.57							Fee Schedule											378							Fee Schedule																																															
DUAL THORAIC DRAIN S	272	RC						Both			34.65	15.59	15.59	31.19	22.52							Fee Schedule		25.64							Fee Schedule																													31.19							Fee Schedule																																															
DULOXETINE 20 MG CAPSULE (CYMBALTA)	250	RC	A9270	CPT				Both			6	2.7	0.01	5.4	0.01							Fee Schedule		4.44							Fee Schedule																													5.4							Fee Schedule																																															
DULOXETINE 30MG CAPSULE (CYMBALTA)	250	RC	A9270	CPT				Both			18.9	8.51	0.01	17.01	0.01							Fee Schedule		13.99							Fee Schedule																													17.01							Fee Schedule																																															
DUO NEB (ALBUTEROL/IPRATROPIUM) UD  (RT)	250	RC	J7620	CPT				Both			7.35	3.31	0.13	6.62	0.13							Fee Schedule		5.44							Fee Schedule		0.21							Fee Schedule											0.2							Fee Schedule		6.62							Fee Schedule		0.23							Fee Schedule		0.19							Fee Schedule											0.23							Fee Schedule		0.19							Fee Schedule		
DUODERM CGF 4X4 DRESSING	250	RC	A9270	CPT				Both			19.95	8.98	0.01	17.96	0.01							Fee Schedule		14.76							Fee Schedule																													17.96							Fee Schedule																																															
DUODERM CGF 6x6 DRESSING	250	RC	A9270	CPT				Both			52.5	23.63	0.01	47.25	0.01							Fee Schedule		38.85							Fee Schedule																													47.25							Fee Schedule																																															
DUODERM CGF 8x9 DRESSING	250	RC	A9270	CPT				Both			54.39	24.48	0.01	48.95	0.01							Fee Schedule		40.25							Fee Schedule																													48.95							Fee Schedule																																															
DURAMORPH 10 MG/10ML INJECTION	636	RC	J2274	CPT				Both			104.25	46.91	17.59	93.83		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	77.15							Fee Schedule		19.48							Fee Schedule											18.91							Fee Schedule		93.83							Fee Schedule		21.75							Fee Schedule		17.59							Fee Schedule											21.75							Fee Schedule		17.59							Fee Schedule		
DURAMORPH 5 MG/10ML INJECTION	636	RC	J2274	CPT				Both			103.53	46.59	17.59	93.18		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	76.61							Fee Schedule		19.48							Fee Schedule											18.91							Fee Schedule		93.18							Fee Schedule		21.75							Fee Schedule		17.59							Fee Schedule											21.75							Fee Schedule		17.59							Fee Schedule		
DURAPREP 26ML 3M #8630	270	RC						Both			11.55	5.2	5.2	10.4	7.51							Fee Schedule		8.55							Fee Schedule																													10.4							Fee Schedule																																															
DURASPHERE INNERSHEATH (CARBON MEDICAL)	272	RC	L8606	CPT				Both			30.45	13.7	13.7	324.12	116.29							Fee Schedule		22.53							Fee Schedule		290.3							Fee Schedule											281.84							Fee Schedule		27.41							Fee Schedule		324.12							Fee Schedule		262.11							Fee Schedule											324.12							Fee Schedule		262.11							Fee Schedule		
DURASPHERE NEEDLE 15 IN. (CARBON MEDICAL	272	RC	L8606	CPT				Both			74.55	33.55	33.55	324.12	116.29							Fee Schedule		55.17							Fee Schedule		290.3							Fee Schedule											281.84							Fee Schedule		67.1							Fee Schedule		324.12							Fee Schedule		262.11							Fee Schedule											324.12							Fee Schedule		262.11							Fee Schedule		
DURASPHERE SYRINGE (CARBON MEDICAL)	272	RC	L8606	CPT				Both			601.65	270.74	116.29	541.49	116.29							Fee Schedule		445.22							Fee Schedule		290.3							Fee Schedule											281.84							Fee Schedule		541.49							Fee Schedule		324.12							Fee Schedule		262.11							Fee Schedule											324.12							Fee Schedule		262.11							Fee Schedule		
DUROLANE 60MG/3ML SYRINGE	636	RC	J7318	CPT				Both			3685.5	1658.48	6.06	3316.95		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	6.73							Fee Schedule		6.72							Fee Schedule											6.52							Fee Schedule		3316.95							Fee Schedule		7.5							Fee Schedule		6.06							Fee Schedule											7.5							Fee Schedule		6.06							Fee Schedule		
DYAZIDE (MAXZIDE 25)	250	RC	A9270	CPT				Both			4.2	1.89	0.01	3.78	0.01							Fee Schedule		3.11							Fee Schedule																													3.78							Fee Schedule																																															
DYNA-HEX FOAM 4OZ #MDS098731	272	RC						Both			8	3.6	3.6	7.2	5.2							Fee Schedule		5.92							Fee Schedule																													7.2							Fee Schedule																																															
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITHOUT CC/MCC					310	DRG		Inpatient			12281.63	5526.73	5526.73	5526.73							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period							0		No services provided during 15 month lookback period				3570.64	3570.64	3570.64	1 through 10									0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period	
EAR CURETTE 6  MICROLOOP 3MM #1222	270	RC						Both			2.1	0.95	0.95	1.89	1.37							Fee Schedule		1.55							Fee Schedule																													1.89							Fee Schedule																																															
EAR CURETTE FLEXLOOP #9555 (SENECA)	270	RC						Both			2.1	0.95	0.95	1.89	1.37							Fee Schedule		1.55							Fee Schedule																													1.89							Fee Schedule																																															
EAR CURETTE INFANTSCOOP #4888	270	RC						Both			2	0.9	0.9	1.8	1.3							Fee Schedule		1.48							Fee Schedule																													1.8							Fee Schedule																																															
EAR CURETTE WITH LIGHT	270	RC						Both			5.25	2.36	2.36	4.73	3.41							Fee Schedule		3.89							Fee Schedule																													4.73							Fee Schedule																																															
EAR MUFFIN KIT W/ELECTRODES(NATUS)	270	RC						Both			39.9	17.96	17.96	35.91	25.94							Fee Schedule		29.53							Fee Schedule																													35.91							Fee Schedule																																															
EAR PHONES&JELLY TABS #040-546/040780	270	RC						Both			34.65	15.59	15.59	31.19	22.52							Fee Schedule		25.64							Fee Schedule																													31.19							Fee Schedule																																															
EAR TIPS DISP. 4-7MM 39422-47-025	270	RC	V5265	CPT				Both			11	4.95	4.95	15.84	15.84							Fee Schedule		8.14							Fee Schedule																													9.9							Fee Schedule																																															
EAR TIPS DISP. 7MM 39422-07-100	270	RC	V5265	CPT				Both			5	2.25	2.25	15.84	15.84							Fee Schedule		3.7							Fee Schedule																													4.5							Fee Schedule																																															
EAR TIPS DISP. 8MM 39422-08-025	270	RC	V5265	CPT				Both			8	3.6	3.6	15.84	15.84							Fee Schedule		5.92							Fee Schedule																													7.2							Fee Schedule																																															
EAR TUBE TITANIUM #145281 (GYRUS)	278	RC						Both			78.75	35.44	35.44	70.88		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	58.28							Fee Schedule																													70.88							Fee Schedule																																															
EAR TUBE TITANIUM #145781	278	RC	A4649	CPT				Both			717	322.65	322.65	645.3		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	530.58							Fee Schedule																													645.3							Fee Schedule																																															
EAR TUBES PAPERALLA	278	RC						Both			49.35	22.21	22.21	44.42		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	36.52							Fee Schedule																													44.42							Fee Schedule																																															
EAR TUBES T TUBE	278	RC						Both			49.35	22.21	22.21	44.42		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	36.52							Fee Schedule																													44.42							Fee Schedule																																															
EAR VENTILATION TUBE #70145780	272	RC						Both			28	12.6	12.6	25.2	18.2							Fee Schedule		20.72							Fee Schedule																													25.2							Fee Schedule																																															
EAR WASH TIPS  (ELEPHANT) TW	270	RC						Both			2.3	1.04	1.04	2.07	1.5							Fee Schedule		1.7							Fee Schedule																													2.07							Fee Schedule																																															
EAR WICK 30-048 (DEROYAL)	272	RC						Both			7	3.15	3.15	6.3	4.55							Fee Schedule		5.18							Fee Schedule																													6.3							Fee Schedule																																															
EAR WICKS POPE MEROCEL 400141	272	RC						Both			21	9.45	9.45	18.9	13.65							Fee Schedule		15.54							Fee Schedule																													18.9							Fee Schedule																																															
SYNCOPE AND COLLAPSE					312	DRG		Inpatient			26329.41	11848.23	11848.23	11848.23							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period				279.47	279.47	279.47	1 through 10						4620.96	4620.96	4620.96	1 through 10									0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period	
EARWAX REMOVAL DROPS-15ML (DEBROX)	250	RC	A9270	CPT				Both			15.75	7.09	0.01	14.18	0.01							Fee Schedule		11.66							Fee Schedule																													14.18							Fee Schedule																																															
EARWICK	272	RC						Both			6.3	2.84	2.84	5.67	4.1							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
EBB HEMORRHAGE CATH # CTS1000	272	RC						Both			1317.75	592.99	592.99	1185.98	856.54							Fee Schedule		975.14							Fee Schedule																													1185.98							Fee Schedule																																															
EBV EPSTEIN BARR PCR 10186 EDTA PLASMA	306	RC	87799	CPT				Both			494.55	222.55	38.07	445.1	38.07							Fee Schedule		47.6							Fee Schedule		44.13							Fee Schedule		42.84							Fee Schedule		42.84							Fee Schedule		445.1							Fee Schedule		49.27							Fee Schedule		39.84							Fee Schedule		42.84							Fee Schedule		49.27							Fee Schedule		39.84							Fee Schedule		
EBV EPSTEIN BARR VIRUS 6421 SCREEN	302	RC	86256	CPT				Both			68.25	30.71	10.71	61.43	10.71							Fee Schedule		13.39							Fee Schedule		12.41							Fee Schedule		12.05							Fee Schedule		12.05							Fee Schedule		61.43							Fee Schedule		13.86							Fee Schedule		11.21							Fee Schedule		12.05							Fee Schedule		13.86							Fee Schedule		11.21							Fee Schedule		
ECHELON FLEX PCEE60A  J&J	272	RC						Both			1618.05	728.12	728.12	1456.25	1051.73							Fee Schedule		1197.36							Fee Schedule																													1456.25							Fee Schedule																																															
ECHINOCOCCOSIS TITER 34271 SERUM	302	RC	86682	CPT				Both			256.2	115.29	11.56	230.58	11.56							Fee Schedule		14.45							Fee Schedule		13.4							Fee Schedule		13.01							Fee Schedule		13.01							Fee Schedule		230.58							Fee Schedule		14.96							Fee Schedule		12.1							Fee Schedule		13.01							Fee Schedule		14.96							Fee Schedule		12.1							Fee Schedule		
ECHO COLOR DOPPLER ADD	483	RC	93325	CPT				Both			500	225	44.29	668	420							Per Diem		370							Fee Schedule											44.29							Fee Schedule											450							Fee Schedule																				668							Per Diem																				
ECHO DOPPLER	483	RC	93306	CPT				Both			2205	992.25	148.77	1984.5	420							Per Diem		1631.7							Fee Schedule											148.77							Fee Schedule											1984.5							Fee Schedule																				668							Per Diem																				
ECHO DOPPLER LTD	483	RC	93308	CPT				Both			2205	992.25	59.09	1984.5	420							Per Diem		1631.7							Fee Schedule											59.09							Fee Schedule											1984.5							Fee Schedule																				668							Per Diem																				
ECHOVIRUS ANTIBODY PANEL 35139 2ML SERUM	302	RC	86658	CPT				Both			1.05	0.47	0.47	14.98	11.58							Fee Schedule		14.47							Fee Schedule		13.42							Fee Schedule		13.03							Fee Schedule		13.03							Fee Schedule		0.95							Fee Schedule		14.98							Fee Schedule		12.12							Fee Schedule		13.03							Fee Schedule		14.98							Fee Schedule		12.12							Fee Schedule		
ECSTASY SERUM 11332	301	RC	80307	CPT				Both			84	37.8	37.8	75.6	51.72							Fee Schedule		64.65							Fee Schedule		64							Fee Schedule		62.14							Fee Schedule		62.14							Fee Schedule		75.6							Fee Schedule		71.46							Fee Schedule		57.79							Fee Schedule		62.14							Fee Schedule		71.46							Fee Schedule		57.79							Fee Schedule		
EDECRIN SODIUM 50 MG/50ML VIAL	250	RC						Both			80.85	36.38	36.38	72.77	52.55							Fee Schedule		59.83							Fee Schedule																													72.77							Fee Schedule																																															
EDROPHONIUM 10 MG/ML- 10 ML MDV	250	RC						Both			12.41	5.58	5.58	11.17	8.07							Fee Schedule		9.18							Fee Schedule																													11.17							Fee Schedule																																															
EDU/TRAIN BREA/MACHI	460	RC	94665	CPT				Both			28.35	12.76	12.76	318	18.43							Fee Schedule		20.98							Fee Schedule																													25.52							Fee Schedule																				318							Per Diem																				
EEG	740	RC	95816	CPT				Both			1050	472.5	40.4	945	275.51							Fee Schedule		777							Fee Schedule											40.4							Fee Schedule											945							Fee Schedule																				286							Per Diem																				
EES 400 MG TABLET	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
EFFERDENT DENTURE CLEANING TABLETS	270	RC						Both			0.76	0.34	0.34	0.68	0.49							Fee Schedule		0.56							Fee Schedule																													0.68							Fee Schedule																																															
EFFEXOR XR 150 MG CAPSULE UD	250	RC	A9270	CPT				Both			11.81	5.31	0.01	10.63	0.01							Fee Schedule		8.74							Fee Schedule																													10.63							Fee Schedule																																															
EFFIENT 5MG TABLET (PRASUGREL)	250	RC	A9270	CPT				Both			27.3	12.29	0.01	24.57	0.01							Fee Schedule		20.2							Fee Schedule																													24.57							Fee Schedule																																															
EFUDEX 5% CREAM-40GM	250	RC	A9270	CPT				Both			551.25	248.06	0.01	496.13	0.01							Fee Schedule		407.93							Fee Schedule																													496.13							Fee Schedule																																															
EHTICON INSUFFLATION NEEDLE PN150	272	RC						Both			190	85.5	85.5	171	123.5							Fee Schedule		140.6							Fee Schedule																													171							Fee Schedule																																															
EHTICON NSLG2S35	272	RC						Both			1796.55	808.45	808.45	1616.9	1167.76							Fee Schedule		1329.45							Fee Schedule																													1616.9							Fee Schedule																																															
EHTICON ONE SEAL	272	RC						Both			19.95	8.98	8.98	17.96	12.97							Fee Schedule		14.76							Fee Schedule																													17.96							Fee Schedule																																															
EKG	730	RC	93005	CPT				Both			283.5	127.58	13.71	286	263							Per Diem		209.79							Fee Schedule											13.71							Fee Schedule											255.15							Fee Schedule																				286							Per Diem																				
EKG INDUSTRIAL MED	730	RC	93005	CPT				Both			137.55	61.9	13.71	286	263							Per Diem		101.79							Fee Schedule											13.71							Fee Schedule											123.8							Fee Schedule																				286							Per Diem																				
EKG MONITOR-SURGERY	270	RC						Both			137.55	61.9	61.9	123.8	89.41							Fee Schedule		101.79							Fee Schedule																													123.8							Fee Schedule																																															
ELASTOPLAST DRESSING	274	RC	A4580	CPT				Both			12.6	5.67	5.67	23.72		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	9.32							Fee Schedule											23.72							Fee Schedule											11.34							Fee Schedule																																															
ELBOW LT	320	RC	73080	CPT				Both			315	141.75	16.3	318	18.51							Fee Schedule		19.02							Fee Schedule											16.3							Fee Schedule											283.5							Fee Schedule																				318							Per Diem																				
ELBOW RT	320	RC	73080	CPT				Both			315	141.75	16.3	318	18.51							Fee Schedule		19.02							Fee Schedule											16.3							Fee Schedule											283.5							Fee Schedule																				318							Per Diem																				
ELECTRODE LLETZ 20MMX15MM SKLAR/SENECA	272	RC						Both			36.75	16.54	16.54	33.08	23.89							Fee Schedule		27.2							Fee Schedule																													33.08							Fee Schedule																																															
ELECTRODE LLETZ 5MM BALL  SKLAR/SENECA	272	RC						Both			30.45	13.7	13.7	27.41	19.79							Fee Schedule		22.53							Fee Schedule																													27.41							Fee Schedule																																															
ELECTRODE LLETZ BALL (MEDLINE) ESE1564	272	RC						Both			45.15	20.32	20.32	40.64	29.35							Fee Schedule		33.41							Fee Schedule																													40.64							Fee Schedule																																															
ELECTRODE LOOP RADIUS 15X12 #12-1512-Y3	272	RC						Both			45	20.25	20.25	40.5	29.25							Fee Schedule		33.3							Fee Schedule																													40.5							Fee Schedule																																															
ELECTRODE LOOP RADIUS 20X10 #12-2010-Y3	272	RC						Both			45	20.25	20.25	40.5	29.25							Fee Schedule		33.3							Fee Schedule																													40.5							Fee Schedule																																															
ELECTRODE LOOP RADIUS 20X13 #12-2013-Y3	272	RC						Both			45	20.25	20.25	40.5	29.25							Fee Schedule		33.3							Fee Schedule																													40.5							Fee Schedule																																															
ELECTRODE LOOP RADIUS 25X10 #12-2510-Y3	272	RC						Both			39.9	17.96	17.96	35.91	25.94							Fee Schedule		29.53							Fee Schedule																													35.91							Fee Schedule																																															
ELECTRODE LOOP RADIUS 5X5MM #12-0505-Y3	272	RC						Both			39.9	17.96	17.96	35.91	25.94							Fee Schedule		29.53							Fee Schedule																													35.91							Fee Schedule																																															
ELECTRODE NEOLEAD (NURSERY)  N305	271	RC						Both			19	8.55	8.55	17.1	12.35							Fee Schedule		14.06							Fee Schedule																													17.1							Fee Schedule																																															
ELECTRODE PEDI SNAP DISP. 8-64-21800	270	RC						Both			2.1	0.95	0.95	1.89	1.37							Fee Schedule		1.55							Fee Schedule																													1.89							Fee Schedule																																															
ELECTRODE SPATULA EPSO2*DISC NO REPLACE*	272	RC						Both			218.4	98.28	98.28	196.56	141.96							Fee Schedule		161.62							Fee Schedule																													196.56							Fee Schedule																																															
ELECTRODES 2  ROUND 566581	271	RC						Both			2	0.9	0.9	1.8	1.3							Fee Schedule		1.48							Fee Schedule																													1.8							Fee Schedule																																															
ELECTRODES 2 X3.5  4/PK 566584	271	RC						Both			2	0.9	0.9	1.8	1.3							Fee Schedule		1.48							Fee Schedule																													1.8							Fee Schedule																																															
ELECTRODES IONTO	271	RC						Both			21	9.45	9.45	18.9	13.65							Fee Schedule		15.54							Fee Schedule																													18.9							Fee Schedule																																															
ELECTRODES ROUND 2  4/PK 081591254	271	RC						Both			2	0.9	0.9	1.8	1.3							Fee Schedule		1.48							Fee Schedule																													1.8							Fee Schedule																																															
ELECTRODES ROUND 2.75   081591288	271	RC						Both			3	1.35	1.35	2.7	1.95							Fee Schedule		2.22							Fee Schedule																													2.7							Fee Schedule																																															
ELECTRODES TAB RESP.TH	271	RC						Both			7.35	3.31	3.31	6.62	4.78							Fee Schedule		5.44							Fee Schedule																													6.62							Fee Schedule																																															
ELECTROLYTE PANEL	301	RC	80051	CPT				Both			262.5	118.13	6.24	236.25	6.24							Fee Schedule		7.79							Fee Schedule		7.22							Fee Schedule		7.01							Fee Schedule		7.01							Fee Schedule		236.25							Fee Schedule		8.06							Fee Schedule		6.52							Fee Schedule		7.01							Fee Schedule		8.06							Fee Schedule		6.52							Fee Schedule		
ELECTRON MICROSCOPY DIAGNOSTIC	310	RC	88348	CPT				Both			2215.5	996.98	177.47	1993.95	177.47							Fee Schedule		257.15							Fee Schedule											359.83							Fee Schedule											1993.95							Fee Schedule																																															
ELECTROSURGICAL ELECTRODE 138102 CONMED	272	RC						Both			3	1.35	1.35	2.7	1.95							Fee Schedule		2.22							Fee Schedule																													2.7							Fee Schedule																																															
ELIDEL 1% TOPICAL CREAM- 30GM TUBE	250	RC	A9270	CPT				Both			598.4	269.28	0.01	538.56	0.01							Fee Schedule		442.82							Fee Schedule																													538.56							Fee Schedule																																															
ELIQUIS 2.5 MG TABLET	250	RC	A9270	CPT				Both			20.73	9.33	0.01	18.66	0.01							Fee Schedule		15.34							Fee Schedule																													18.66							Fee Schedule																																															
ELIQUIS 5 MG TABLET	250	RC	A9270	CPT				Both			20.73	9.33	0.01	18.66	0.01							Fee Schedule		15.34							Fee Schedule																													18.66							Fee Schedule																																															
ELIXOPHYLLIN ELIXIR 15ML UD	250	RC	A9270	CPT				Both			12.6	5.67	0.01	11.34	0.01							Fee Schedule		9.32							Fee Schedule																													11.34							Fee Schedule																																															
ELLIK EVACUATOR	271	RC						Both			39.9	17.96	17.96	35.91	25.94							Fee Schedule		29.53							Fee Schedule																													35.91							Fee Schedule																																															
ELLIK EVACUATOR 000451	271	RC						Both			67.2	30.24	30.24	60.48	43.68							Fee Schedule		49.73							Fee Schedule																													60.48							Fee Schedule																																															
ELMIRON 100 MG CAPSULE UD	250	RC	A9270	CPT				Both			9.45	4.25	0.01	8.51	0.01							Fee Schedule		6.99							Fee Schedule																													8.51							Fee Schedule																																															
ELPERENONE 25 MG (INSPRA) TABLET UD	250	RC	A9270	CPT				Both			12.92	5.81	0.01	11.63	0.01							Fee Schedule		9.56							Fee Schedule																													11.63							Fee Schedule																																															
EMERGENCY BIRTHING TRAY DYNJS0600	270	RC						Both			64	28.8	28.8	57.6	41.6							Fee Schedule		47.36							Fee Schedule																													57.6							Fee Schedule																																															
EMERGENCY ROOM 1	450	RC	99281	CPT				Outpatient			420	189	44	530	330							Case Rate		352							Fee Schedule		82.81							Fee Schedule		44							Fee Schedule		82.81							Fee Schedule		378							Fee Schedule		85.57							Fee Schedule		300							Case Rate		530							Case Rate		85.57							Fee Schedule		179							Case Rate		
EMERGENCY ROOM 2	450	RC	99282	CPT				Outpatient			787.5	354.38	54	1061	440							Case Rate		440							Fee Schedule		142.78							Fee Schedule		54							Fee Schedule		142.78							Fee Schedule		708.75							Fee Schedule		166.29							Fee Schedule		300							Case Rate		1061							Case Rate		166.29							Fee Schedule		296							Case Rate		
EMERGENCY ROOM 3	450	RC	99283	CPT				Outpatient			1575	708.75	97	2122	845							Case Rate		770							Fee Schedule		253.84							Fee Schedule		97							Fee Schedule		253.84							Fee Schedule		1417.5							Fee Schedule		283.42							Fee Schedule		300							Case Rate		2122							Case Rate		283.42							Fee Schedule		477							Case Rate		
EMERGENCY ROOM 4	450	RC	99284	CPT				Outpatient			3150	1417.5	148	4244	1500							Case Rate		1347							Fee Schedule		388.02							Fee Schedule		148							Fee Schedule		388.02							Fee Schedule		2835							Fee Schedule		433.23							Fee Schedule		300							Case Rate		4244							Case Rate		433.23							Fee Schedule		915							Case Rate		
EMERGENCY ROOM 5	450	RC	99285	CPT				Outpatient			3675	1653.75	273	5517	1800							Case Rate		2021							Fee Schedule		553.79							Fee Schedule		273							Fee Schedule		553.79							Fee Schedule		3307.5							Fee Schedule		618.31							Fee Schedule		300							Case Rate		5517							Case Rate		618.31							Fee Schedule		1032							Case Rate		
EMERGENCY SURVIVAL BLANKET 52X84 405799	270	RC						Both			7.74	3.48	3.48	6.97	5.03							Fee Schedule		5.73							Fee Schedule																													6.97							Fee Schedule																																															
EMLA CREAM 2.5% CREAM- 30 GM TUBE	250	RC	A9270	CPT				Both			23.1	10.4	0.01	20.79	0.01							Fee Schedule		17.09							Fee Schedule																													20.79							Fee Schedule																																															
ENABLEX 7.5MG (DARIFENACIN) TABLET	250	RC	A9270	CPT				Both			16.38	7.37	0.01	14.74	0.01							Fee Schedule		12.12							Fee Schedule																													14.74							Fee Schedule																																															
ENALAPRIL 10MG (VASOTEC) TABLET	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
ENALAPRIL 5MG (VASOTEC) TABLET	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
ENALAPRILAT 1.25 MG/ML (VASOTEC) INJ	250	RC	A9270	CPT				Both			23.1	10.4	0.01	20.79	0.01							Fee Schedule		17.09							Fee Schedule																													20.79							Fee Schedule																																															
ENBOLOGIX MAIN BODY BA28-80/I20-40	278	RC	C1768	CPT				Both			36477	16414.65	16414.65	32829.3		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	26992.98							Fee Schedule																													32829.3							Fee Schedule																																															
ENCORE 26 INFLATION DEVICE M0067101131	272	RC						Both			106	47.7	47.7	95.4	68.9							Fee Schedule		78.44							Fee Schedule																													95.4							Fee Schedule																																															
END CAP	278	RC						Both			242.55	109.15	109.15	218.3		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	179.49							Fee Schedule																													218.3							Fee Schedule																																															
ENDO BITES	271	RC						Both			7.35	3.31	3.31	6.62	4.78							Fee Schedule		5.44							Fee Schedule																													6.62							Fee Schedule																																															
ENDO LIGATOR SG  #000227  CONMED	272	RC						Both			315	141.75	141.75	283.5	204.75							Fee Schedule		233.1							Fee Schedule																													283.5							Fee Schedule																																															
ENDO TRAC TUBE HOLDER #ET-1520	270	RC	A4625	CPT				Both			12.6	5.67	5.3	11.34	5.3							Fee Schedule		9.32							Fee Schedule		8.64							Fee Schedule		6.62							Fee Schedule											11.34							Fee Schedule																																															
ENDO TRAC TUBE INTROD. # 9-0212-70	272	RC						Both			19	8.55	7.8	17.1	12.35							Fee Schedule		14.06							Fee Schedule																				8.39							Fee Schedule		17.1							Fee Schedule		9.65							Fee Schedule		7.8							Fee Schedule											9.65							Fee Schedule		7.8							Fee Schedule		
ENDO TRAC TUBE REINFORCED 8.0	272	RC						Both			63	28.35	28.35	56.7	40.95							Fee Schedule		46.62							Fee Schedule																													56.7							Fee Schedule																																															
ENDOBAG #POUCH   (SENECA)	272	RC						Both			449.4	202.23	202.23	404.46	292.11							Fee Schedule		332.56							Fee Schedule																													404.46							Fee Schedule																																															
ENDOCAVITY NEEDLE GUIDE KIT 1-535-9001	272	RC						Both			51	22.95	22.95	45.9	33.15							Fee Schedule		37.74							Fee Schedule																													45.9							Fee Schedule																																															
ENDOCAVITY NEEDLE GUIDE KIT 1-535-9003	272	RC						Both			51	22.95	22.95	45.9	33.15							Fee Schedule		37.74							Fee Schedule																													45.9							Fee Schedule																																															
CHEST PAIN					313	DRG		Inpatient			22599.25	10169.66	10169.66	10169.66							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period				2227.09	2227.09	2227.09	1 through 10									0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period	
ENDOGAUGE	272	RC						Both			54.6	24.57	24.57	49.14	35.49							Fee Schedule		40.4							Fee Schedule																													49.14							Fee Schedule																																															
ENDOJUDGE EJ10G	272	RC						Both			136	61.2	61.2	122.4	88.4							Fee Schedule		100.64							Fee Schedule																													122.4							Fee Schedule																																															
ENDOLAGIX EXTENSION 120-13/C88F SA	278	RC						Both			11021.85	4959.83	4959.83	9919.67		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	8156.17							Fee Schedule																													9919.67							Fee Schedule																																															
ENDOLAGIX VELA SUPRARENAL F00786-12	278	RC	C1875	CPT				Both			16691.85	7511.33	7511.33	15022.67		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	12351.97							Fee Schedule																													15022.67							Fee Schedule																																															
ENDOLOGIX  ABD AORTIC STINT F00820-40	278	RC	C1768	CPT				Both			44096.85	19843.58	19843.58	39687.17		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	32631.67							Fee Schedule																													39687.17							Fee Schedule																																															
ENDOLOGIX  ABD AORTIC STINT F00820-54	278	RC	C1768	CPT				Both			45671.85	20552.33	20552.33	41104.67		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	33797.17							Fee Schedule																													41104.67							Fee Schedule																																															
ENDOLOGIX  AUTOINJECTOR TV-A101-E	272	RC						Both			1571.85	707.33	707.33	1414.67	1021.7							Fee Schedule		1163.17							Fee Schedule																													1414.67							Fee Schedule																																															
ENDOLOGIX  BIF. GRAFT BEA28-120/I20-40	278	RC	C1768	CPT				Both			45671.85	20552.33	20552.33	41104.67		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	33797.17							Fee Schedule																													41104.67							Fee Schedule																																															
ENDOLOGIX  CUSTOM SEAL KIT TV-CS14-G	272	RC						Both			3146.85	1416.08	1416.08	2832.17	2045.45							Fee Schedule		2328.67							Fee Schedule																													2832.17							Fee Schedule																																															
ENDOLOGIX  ENDO SNARE F00305	272	RC						Both			1275.75	574.09	574.09	1148.18	829.24							Fee Schedule		944.06							Fee Schedule																													1148.18							Fee Schedule																																															
ENDOLOGIX  HVA VALVE F00352	272	RC						Both			78.75	35.44	35.44	70.88	51.19							Fee Schedule		58.28							Fee Schedule																													70.88							Fee Schedule																																															
ENDOLOGIX  LIMB EXTENSION TV-EX282845-J	278	RC	C1768	CPT				Both			17321.85	7794.83	7794.83	15589.67		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	12818.17							Fee Schedule																													15589.67							Fee Schedule																																															
ENDOLOGIX  LIMB EXTENSION TV-IL141014-J	278	RC	C1768	CPT				Both			17321.85	7794.83	7794.83	15589.67		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	12818.17							Fee Schedule																													15589.67							Fee Schedule																																															
ENDOLOGIX  MAIN BODY BA22-40/113-40	278	RC	C1768	CPT				Both			44100	19845	19845	39690		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	32634							Fee Schedule																													39690							Fee Schedule																																															
ENDOLOGIX  MAIN BODY BEA22-70/I20-30	278	RC	C1768	CPT				Both			45671.85	20552.33	20552.33	41104.67		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	33797.17							Fee Schedule																													41104.67							Fee Schedule																																															
ENDOLOGIX  MAIN BODY BEA25-100/I20-40	278	RC	C1768	CPT				Both			45671.85	20552.33	20552.33	41104.67		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	33797.17							Fee Schedule																													41104.67							Fee Schedule																																															
ENDOLOGIX  MAIN BODY BEA25-60/I16-40	278	RC	C1768	CPT				Both			45671.85	20552.33	20552.33	41104.67		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	33797.17							Fee Schedule																													41104.67							Fee Schedule																																															
ENDOLOGIX  MAIN BODY BEA25-80/113-4	278	RC	C1768	CPT				Both			47246.85	21261.08	21261.08	42522.17		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	34962.67							Fee Schedule																													42522.17							Fee Schedule																																															
ENDOLOGIX  MAIN BODY BEA25-80/I16-40	278	RC	C1768	CPT				Both			47246.85	21261.08	21261.08	42522.17		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	34962.67							Fee Schedule																													42522.17							Fee Schedule																																															
ENDOLOGIX  MAIN BODY BEA25-80/I16-55	278	RC	C1768	CPT				Both			45671.85	20552.33	20552.33	41104.67		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	33797.17							Fee Schedule																													41104.67							Fee Schedule																																															
ENDOLOGIX  MAIN BODY BEA28-110/I16-30	278	RC	C1768	CPT				Both			47246.85	21261.08	21261.08	42522.17		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	34962.67							Fee Schedule																													42522.17							Fee Schedule																																															
ENDOLOGIX  MAIN BODY BEA28-110/I20-30	278	RC	C1768	CPT				Both			45671.85	20552.33	20552.33	41104.67		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	33797.17							Fee Schedule																													41104.67							Fee Schedule																																															
ENDOLOGIX  OVATION TV-EX101045-J	278	RC	C1768	CPT				Both			17321.85	7794.83	7794.83	15589.67		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	12818.17							Fee Schedule																													15589.67							Fee Schedule																																															
ENDOLOGIX  OVATION TV-EX222245-J	278	RC	C1768	CPT				Both			17321.85	7794.83	7794.83	15589.67		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	12818.17							Fee Schedule																													15589.67							Fee Schedule																																															
ENDOLOGIX  SUPRARENAL F00786-08	278	RC	C1875	CPT				Both			16691.85	7511.33	7511.33	15022.67		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	12351.97							Fee Schedule																													15022.67							Fee Schedule																																															
ENDOLOGIX  SUPRARENAL F00786-09	278	RC	C1875	CPT				Both			17321.85	7794.83	7794.83	15589.67		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	12818.17							Fee Schedule																													15589.67							Fee Schedule																																															
ENDOLOGIX ABD AORTIC STINT F00820-35	278	RC	C1768	CPT				Both			47246.85	21261.08	21261.08	42522.17		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	34962.67							Fee Schedule																													42522.17							Fee Schedule																																															
ENDOLOGIX ABD GRAFT TV-AB2980-J	278	RC	C1768	CPT				Both			39371.85	17717.33	17717.33	35434.67		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	29135.17							Fee Schedule																													35434.67							Fee Schedule																																															
ENDOLOGIX BIFUR MAIN BODY BA22-60/113-40	278	RC	C1768	CPT				Both			36477	16414.65	16414.65	32829.3		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	26992.98							Fee Schedule																													32829.3							Fee Schedule																																															
ENDOLOGIX ENSNARE 100CM F00572	272	RC						Both			1464.75	659.14	659.14	1318.28	952.09							Fee Schedule		1083.92							Fee Schedule																													1318.28							Fee Schedule																																															
ENDOLOGIX ENSNARE 30MM # EN2007030	272	RC	C1773	CPT				Both			1275.75	574.09	70	1148.18	70							Fee Schedule		944.06							Fee Schedule																													1148.18							Fee Schedule																																															
ENDOLOGIX ENSNARE 30MM # ENZ007030	272	RC	C1773	CPT				Both			1275.75	574.09	70	1148.18	70							Fee Schedule		944.06							Fee Schedule																													1148.18							Fee Schedule																																															
ENDOLOGIX ENSNARE 45MM # EN2007045	272	RC	C1773	CPT				Both			945	425.25	70	850.5	70							Fee Schedule		699.3							Fee Schedule																													850.5							Fee Schedule																																															
ENDOLOGIX FILL POLYMER KIT TV-FP14-E	272	RC						Both			3146.85	1416.08	1416.08	2832.17	2045.45							Fee Schedule		2328.67							Fee Schedule																													2832.17							Fee Schedule																																															
ENDOLOGIX GUIDEWIRE .014  # 4104	272	RC	C1769	CPT				Both			567	255.15	154.26	510.3	154.26							Fee Schedule		419.58							Fee Schedule																													510.3							Fee Schedule																																															
ENDOLOGIX GUIDEWIRE .035  # 4804	272	RC	C1769	CPT				Both			519.75	233.89	154.26	467.78	154.26							Fee Schedule		384.62							Fee Schedule																													467.78							Fee Schedule																																															
ENDOLOGIX GUIDEWIRE .035  C00651	272	RC	C1769	CPT				Both			551.25	248.06	154.26	496.13	154.26							Fee Schedule		407.93							Fee Schedule																													496.13							Fee Schedule																																															
ENDOLOGIX GUIDEWIRE .035  F00330	272	RC	C1769	CPT				Both			519.75	233.89	154.26	467.78	154.26							Fee Schedule		384.62							Fee Schedule																													467.78							Fee Schedule																																															
ENDOLOGIX GUIDEWIRE .035  F00839	272	RC	C1769	CPT				Both			519.75	233.89	154.26	467.78	154.26							Fee Schedule		384.62							Fee Schedule																													467.78							Fee Schedule																																															
ENDOLOGIX GUIDEWIRE F00330	272	RC	C1769	CPT				Both			519.75	233.89	154.26	467.78	154.26							Fee Schedule		384.62							Fee Schedule																													467.78							Fee Schedule																																															
ENDOLOGIX GUIDEWIRE F00467	272	RC	C1769	CPT				Both			567	255.15	154.26	510.3	154.26							Fee Schedule		419.58							Fee Schedule																													510.3							Fee Schedule																																															
ENDOLOGIX GUIDEWIRE F00839	272	RC	C1769	CPT				Both			563.85	253.73	154.26	507.47	154.26							Fee Schedule		417.25							Fee Schedule																													507.47							Fee Schedule																																															
ENDOLOGIX HEMOSTATIC VALVE # HVA-100	272	RC						Both			78.75	35.44	35.44	70.88	51.19							Fee Schedule		58.28							Fee Schedule																													70.88							Fee Schedule																																															
ENDOLOGIX INTROD. SHEATH # S17-45	272	RC	C1894	CPT				Both			1571.85	707.33	87.34	1414.67	87.34							Fee Schedule		1163.17							Fee Schedule																													1414.67							Fee Schedule																																															
ENDOLOGIX INTRODUCER F00511	272	RC	C1894	CPT				Both			1571.85	707.33	87.34	1414.67	87.34							Fee Schedule		1163.17							Fee Schedule																													1414.67							Fee Schedule																																															
ENDOLOGIX LIMB EXTENSION TV-IL1410100-J	278	RC	C1768	CPT				Both			17321.85	7794.83	7794.83	15589.67		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	12818.17							Fee Schedule																													15589.67							Fee Schedule																																															
ENDOLOGIX OVATION AUTOINJECTOR TV-AI01-E	272	RC						Both			787.5	354.38	354.38	708.75	511.88							Fee Schedule		582.75							Fee Schedule																													708.75							Fee Schedule																																															
ENDOLOGIX OVATION STENT TV-AB2980-J	278	RC	C1768	CPT				Both			39371.85	17717.33	17717.33	35434.67		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	29135.17							Fee Schedule																													35434.67							Fee Schedule																																															
ENDOLOGIX OVATION STENT TV-IL1410120-J	278	RC	C1768	CPT				Both			17321.85	7794.83	7794.83	15589.67		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	12818.17							Fee Schedule																													15589.67							Fee Schedule																																															
ENDOLOGIX OVATION STENT TV-IL141080-J	278	RC	C1768	CPT				Both			17321.85	7794.83	7794.83	15589.67		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	12818.17							Fee Schedule																													15589.67							Fee Schedule																																															
ENDOLOGIX OVATION STENT TV-IL1412100-J	278	RC	C1875	CPT				Both			17321.85	7794.83	7794.83	15589.67		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	12818.17							Fee Schedule																													15589.67							Fee Schedule																																															
ENDOLOGIX STENT TV-IL1410160-J	278	RC	C1768	CPT				Both			17321.85	7794.83	7794.83	15589.67		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	12818.17							Fee Schedule																													15589.67							Fee Schedule																																															
ENDOLOGIX STENTA28-28/C95-020V	278	RC	C1875	CPT				Both			17321.85	7794.83	7794.83	15589.67		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	12818.17							Fee Schedule																													15589.67							Fee Schedule																																															
ENDOLOGIX SUPRARENAL A34-34/C100-O20 V	278	RC	C1875	CPT				Both			17321.85	7794.83	7794.83	15589.67		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	12818.17							Fee Schedule																													15589.67							Fee Schedule																																															
ENDOLOGIX VELA INFRARENAL   A25-25/C75V	278	RC	C1768	CPT				Both			17321.85	7794.83	7794.83	15589.67		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	12818.17							Fee Schedule																													15589.67							Fee Schedule																																															
ENDOLOGIX VELA INFRARENAL   A28-28/C75V	278	RC	C1875	CPT				Both			17321.85	7794.83	7794.83	15589.67		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	12818.17							Fee Schedule																													15589.67							Fee Schedule																																															
ENDOLOGIX VELA SUPRARENAL A25-25/C95-O20	278	RC	C1768	CPT				Both			17321.85	7794.83	7794.83	15589.67		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	12818.17							Fee Schedule																													15589.67							Fee Schedule																																															
ENDOLOOP CHROMIC EZ10G	272	RC						Both			136	61.2	61.2	122.4	88.4							Fee Schedule		100.64							Fee Schedule																													122.4							Fee Schedule																																															
ENDOLOOP PDS II  EZ10G	272	RC						Both			136	61.2	61.2	122.4	88.4							Fee Schedule		100.64							Fee Schedule																													122.4							Fee Schedule																																															
ENDOLOOP VICRYL EJ10G	272	RC						Both			150	67.5	67.5	135	97.5							Fee Schedule		111							Fee Schedule																													135							Fee Schedule																																															
ENDOMETRIAL CURETTE 3MM #MX140	272	RC						Both			24	10.8	10.8	21.6	15.6							Fee Schedule		17.76							Fee Schedule																													21.6							Fee Schedule																																															
ENDOMETRIAL CURETTE 3MM SOFT #MX145	272	RC						Both			24	10.8	10.8	21.6	15.6							Fee Schedule		17.76							Fee Schedule																													21.6							Fee Schedule																																															
ENDOMETRIAL CURETTE 4MM #MX150	272	RC						Both			24	10.8	10.8	21.6	15.6							Fee Schedule		17.76							Fee Schedule																													21.6							Fee Schedule																																															
ENDOMETRIAL PIPELLES  8200	272	RC						Both			26	11.7	11.7	23.4	16.9							Fee Schedule		19.24							Fee Schedule																													23.4							Fee Schedule																																															
ENDOMETRIAL PIPELLES (PEGRAM) #908015	272	RC						Both			20	9	9	18	13							Fee Schedule		14.8							Fee Schedule																													18							Fee Schedule																																															
ENDOMYSIAL ANTIBODIES 15064 SER 1ML	302	RC	86255	CPT				Both			204.75	92.14	10.71	184.28	10.71							Fee Schedule		13.39							Fee Schedule		12.41							Fee Schedule		12.05							Fee Schedule											184.28							Fee Schedule																				12.05							Fee Schedule																				
ENDOSCOPE VALVE DEFENDO #100305	272	RC						Both			24.15	10.87	10.87	21.74	15.7							Fee Schedule		17.87							Fee Schedule																				12.05							Fee Schedule		21.74							Fee Schedule		13.86							Fee Schedule		11.21							Fee Schedule											13.86							Fee Schedule		11.21							Fee Schedule		
ENDOSCOPY PROCEDURE PACK  MEDLINE	270	RC						Both			23.1	10.4	10.4	20.79	15.02							Fee Schedule		17.09							Fee Schedule																													20.79							Fee Schedule																																															
ENDOSPONGE #LA9405 (V-MUELLER)	272	RC						Both			44.1	19.85	19.85	39.69	28.67							Fee Schedule		32.63							Fee Schedule																													39.69							Fee Schedule																																															
ENDOTRACH TUBE HI/LO#124-60-2  SIZE 6	272	RC						Both			43.05	19.37	19.37	38.75	27.98							Fee Schedule		31.86							Fee Schedule																													38.75							Fee Schedule																																															
ENDOTRACH TUBE HI/LO#124-70-2  SIZE 7	272	RC						Both			43.05	19.37	19.37	38.75	27.98							Fee Schedule		31.86							Fee Schedule																													38.75							Fee Schedule																																															
ENDOTRACH TUBE HI/LO#124-75-2  SIZE7.5	272	RC						Both			43.05	19.37	19.37	38.75	27.98							Fee Schedule		31.86							Fee Schedule																													38.75							Fee Schedule																																															
ENDOTRACH TUBE HI/LO#124-80-2  SIZE 8	272	RC						Both			43.05	19.37	19.37	38.75	27.98							Fee Schedule		31.86							Fee Schedule																													38.75							Fee Schedule																																															
ENDOTRACH TUBE ORAL RAE 7.0	272	RC						Both			15.75	7.09	7.09	14.18	10.24							Fee Schedule		11.66							Fee Schedule																													14.18							Fee Schedule																																															
ENDOTRACHEAL TUBE 10.0 #18710S	272	RC						Both			8.4	3.78	3.78	7.56	5.46							Fee Schedule		6.22							Fee Schedule																													7.56							Fee Schedule																																															
ENDOTRACHEAL TUBE 2.0 UNCUFFED #86232	272	RC						Both			5	2.25	2.25	4.5	3.25							Fee Schedule		3.7							Fee Schedule																													4.5							Fee Schedule																																															
ENDOTRACHEAL TUBE 2.5 UNCUFFED 86233	272	RC						Both			5	2.25	2.25	4.5	3.25							Fee Schedule		3.7							Fee Schedule																													4.5							Fee Schedule																																															
ENDOTRACHEAL TUBE 3.0  5-10406	272	RC						Both			4	1.8	1.8	3.6	2.6							Fee Schedule		2.96							Fee Schedule																													3.6							Fee Schedule																																															
ENDOTRACHEAL TUBE 3.5 CUFFED 112480035	272	RC						Both			6	2.7	2.7	5.4	3.9							Fee Schedule		4.44							Fee Schedule																													5.4							Fee Schedule																																															
ENDOTRACHEAL TUBE 3.5 UNCUFFED 100382035	272	RC						Both			3.15	1.42	1.42	2.84	2.05							Fee Schedule		2.33							Fee Schedule																													2.84							Fee Schedule																																															
ENDOTRACHEAL TUBE 4.0 CUFFED 86045	272	RC						Both			11	4.95	4.95	9.9	7.15							Fee Schedule		8.14							Fee Schedule																													9.9							Fee Schedule																																															
ENDOTRACHEAL TUBE 4.0 UNCUFFED 100382040	272	RC						Both			3	1.35	1.35	2.7	1.95							Fee Schedule		2.22							Fee Schedule																													2.7							Fee Schedule																																															
ENDOTRACHEAL TUBE 4.5 86445	272	RC						Both			8	3.6	3.6	7.2	5.2							Fee Schedule		5.92							Fee Schedule																													7.2							Fee Schedule																																															
ENDOTRACHEAL TUBE 4.5 CUFFED  111781045	272	RC						Both			14	6.3	6.3	12.6	9.1							Fee Schedule		10.36							Fee Schedule																													12.6							Fee Schedule																																															
ENDOTRACHEAL TUBE 4.5 UNCUFFED 100382045	272	RC						Both			3.15	1.42	1.42	2.84	2.05							Fee Schedule		2.33							Fee Schedule																													2.84							Fee Schedule																																															
ENDOTRACHEAL TUBE 5.0 #86446	272	RC						Both			7	3.15	3.15	6.3	4.55							Fee Schedule		5.18							Fee Schedule																													6.3							Fee Schedule																																															
ENDOTRACHEAL TUBE 5.5 #86447	272	RC						Both			7	3.15	3.15	6.3	4.55							Fee Schedule		5.18							Fee Schedule																													6.3							Fee Schedule																																															
ENDOTRACHEAL TUBE 6.0 #86448	272	RC						Both			8	3.6	3.6	7.2	5.2							Fee Schedule		5.92							Fee Schedule																													7.2							Fee Schedule																																															
ENDOTRACHEAL TUBE 6.5 #86449	272	RC						Both			8	3.6	3.6	7.2	5.2							Fee Schedule		5.92							Fee Schedule																													7.2							Fee Schedule																																															
ENDOTRACHEAL TUBE 7.0 #86450	272	RC						Both			11	4.95	4.95	9.9	7.15							Fee Schedule		8.14							Fee Schedule																													9.9							Fee Schedule																																															
ENDOTRACHEAL TUBE 7.5 #86451	272	RC						Both			11	4.95	4.95	9.9	7.15							Fee Schedule		8.14							Fee Schedule																													9.9							Fee Schedule																																															
ENDOTRACHEAL TUBE 8.0 #86452	272	RC						Both			11	4.95	4.95	9.9	7.15							Fee Schedule		8.14							Fee Schedule																													9.9							Fee Schedule																																															
ENDOTRACHEAL TUBE 8.5  #86453	272	RC						Both			7	3.15	3.15	6.3	4.55							Fee Schedule		5.18							Fee Schedule																													6.3							Fee Schedule																																															
ENDOTRACHEAL TUBE 9.0  #86454	272	RC						Both			7	3.15	3.15	6.3	4.55							Fee Schedule		5.18							Fee Schedule																													6.3							Fee Schedule																																															
ENDOTRACHEAL TUBE LO-PRO 6.0MM 86049	272	RC						Both			7	3.15	3.15	6.3	4.55							Fee Schedule		5.18							Fee Schedule																													6.3							Fee Schedule																																															
ENDOVIVE 18FR STRAIGHT G-TUBE #M00509911	270	RC	B4087	CPT				Both			121	54.45	14.31	108.9	14.31							Fee Schedule		89.54							Fee Schedule																													108.9							Fee Schedule																																															
ENDOVIVE 24F PEG TUBE KIT #M00509021	272	RC						Both			1118	503.1	503.1	1006.2	726.7							Fee Schedule		827.32							Fee Schedule																													1006.2							Fee Schedule																																															
ENDOVIVE 24F PUSH PEG KIT #M00509071	272	RC						Both			593	266.85	266.85	533.7	385.45							Fee Schedule		438.82							Fee Schedule																													533.7							Fee Schedule																																															
ENDOVIVE 24FR STRAIGHT G-TUBE #M00509941	270	RC	B4087	CPT				Both			121	54.45	14.31	108.9	14.31							Fee Schedule		89.54							Fee Schedule																													108.9							Fee Schedule																																															
ENDU TROL TUBES	271	RC						Both			34.65	15.59	15.59	31.19	22.52							Fee Schedule		25.64							Fee Schedule																													31.19							Fee Schedule																																															
ENDURON 5 MG TABLET	250	RC	A9270	CPT				Both			4.2	1.89	0.01	3.78	0.01							Fee Schedule		3.11							Fee Schedule																													3.78							Fee Schedule																																															
ENFIT TRANSITION CONNECTOR #F00071ED	272	RC						Both			4	1.8	1.8	3.6	2.6							Fee Schedule		2.96							Fee Schedule																													3.6							Fee Schedule																																															
ENGERIX-B (HEP-B PED) 10MCG/0.5ML VACC	636	RC	90744	CPT				Both			98.04	44.12	34.22	88.24		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	72.55							Fee Schedule		34.22							Fee Schedule		34.5							Fee Schedule											88.24							Fee Schedule																																															
ENGERIX-B 10MCG/0.5ML VACCINE SYRINGE	636	RC	90744	CPT				Both			44.1	19.85	19.85	39.69		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	32.63							Fee Schedule		34.22							Fee Schedule		34.5							Fee Schedule		33.22							Fee Schedule		39.69							Fee Schedule		38.2							Fee Schedule		30.89							Fee Schedule											38.2							Fee Schedule		30.89							Fee Schedule		
ENGERIX-B 20MCG/ML ADULT VACCINE	636	RC	90740	CPT				Both			86.1	38.75	30.89	176.07		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	63.71							Fee Schedule		176.07							Fee Schedule											33.22							Fee Schedule		77.49							Fee Schedule		38.2							Fee Schedule		30.89							Fee Schedule											38.2							Fee Schedule		30.89							Fee Schedule		
ENOXAPARIN SODIUM 300MG/3ML VIAL	636	RC	J1650	CPT				Both			230.94	103.92	0.55	207.85		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	170.9							Fee Schedule		0.55							Fee Schedule		21.6							Fee Schedule		170.94							Fee Schedule		207.85							Fee Schedule		196.58							Fee Schedule		158.98							Fee Schedule											196.58							Fee Schedule		158.98							Fee Schedule		
ENSURE (240ML CAN)	250	RC	B4150	CPT				Both			6.3	2.84	0.21	5.67	0.21							Fee Schedule		4.66							Fee Schedule											0.84							Fee Schedule		0.54							Fee Schedule		5.67							Fee Schedule		0.62							Fee Schedule		0.5							Fee Schedule											0.62							Fee Schedule		0.5							Fee Schedule		
ENSURE 240ML CAN	250	RC						Both			2.45	1.1	1.1	2.21	1.59							Fee Schedule		1.81							Fee Schedule																													2.21							Fee Schedule																																															
ENSURE CHOCOLATE	271	RC						Both			4.2	1.89	1.89	3.78	2.73							Fee Schedule		3.11							Fee Schedule																													3.78							Fee Schedule																																															
ENSURE PLUS BUTTER PECAN	271	RC						Both			6.3	2.84	2.84	5.67	4.1							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
ENSURE PLUS CHOCOLATE	271	RC						Both			6.3	2.84	2.84	5.67	4.1							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
ENSURE PLUS STRAWBERRY	271	RC						Both			6.3	2.84	2.84	5.67	4.1							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
ENSURE PLUS VANILLA	271	RC						Both			6.3	2.84	2.84	5.67	4.1							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
ENSURE PUDDING BUTTERSCOTCH	272	RC						Both			4.2	1.89	1.89	3.78	2.73							Fee Schedule		3.11							Fee Schedule																													3.78							Fee Schedule																																															
ENSURE PUDDING CHOCOLATE	271	RC						Both			4.2	1.89	1.89	3.78	2.73							Fee Schedule		3.11							Fee Schedule																													3.78							Fee Schedule																																															
ENSURE STRAWBERRY	271	RC						Both			4.2	1.89	1.89	3.78	2.73							Fee Schedule		3.11							Fee Schedule																													3.78							Fee Schedule																																															
ENSURE VANILLA 50460	271	RC						Both			6.3	2.84	2.84	5.67	4.1							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
ENT CUTTER 60 DEGREE 4MM 5290-640-100	272	RC						Both			449	202.05	202.05	404.1	291.85							Fee Schedule		332.26							Fee Schedule																													404.1							Fee Schedule																																															
ENT CUTTER AGGRESSIVE 2.5MM 5290-628-000	272	RC						Both			445	200.25	200.25	400.5	289.25							Fee Schedule		329.3							Fee Schedule																													400.5							Fee Schedule																																															
ENT CUTTER SERRATED 4MM 5290-645-000	272	RC						Both			502	225.9	225.9	451.8	326.3							Fee Schedule		371.48							Fee Schedule																													451.8							Fee Schedule																																															
ENTAMOEBA HISTOLYTICA AB IGG 34278 SERUM	302	RC	86753	CPT				Both			183.75	82.69	11.01	165.38	11.01							Fee Schedule		13.76							Fee Schedule		12.76							Fee Schedule		12.39							Fee Schedule											165.38							Fee Schedule																				12.39							Fee Schedule																				
ENTAMOEBA HISTOLYTICA AG 34964 STOOL	306	RC	87337	CPT				Both			86.1	38.75	10.66	77.49	10.66							Fee Schedule		13.32							Fee Schedule		12.34							Fee Schedule		11.98							Fee Schedule		12.39							Fee Schedule		77.49							Fee Schedule		14.25							Fee Schedule		11.52							Fee Schedule		11.98							Fee Schedule		14.25							Fee Schedule		11.52							Fee Schedule		
ENTEROVIRUS PANEL 91811 6ML SERUM	302	RC	86658	CPT				Both			1.05	0.47	0.47	14.47	11.58							Fee Schedule		14.47							Fee Schedule		13.42							Fee Schedule		13.03							Fee Schedule		11.98							Fee Schedule		0.95							Fee Schedule		13.78							Fee Schedule		11.14							Fee Schedule		13.03							Fee Schedule		13.78							Fee Schedule		11.14							Fee Schedule		
ENTRESTO 24MG/26MG TABLET	250	RC	A9270	CPT				Both			32.55	14.65	0.01	29.3	0.01							Fee Schedule		24.09							Fee Schedule																				13.03							Fee Schedule		29.3							Fee Schedule		14.98							Fee Schedule		12.12							Fee Schedule											14.98							Fee Schedule		12.12							Fee Schedule		
ENTYVIO INTRAVENOUS PWD FOR SOLN 300MG	636	RC	J3380	CPT				Both			33695.67	15163.05	20.98	30326.1		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	20.98							Fee Schedule		22.01							Fee Schedule																				30326.1							Fee Schedule																																															
ePHEDrine 50 MG/ML VIAL	250	RC	A9270	CPT				Both			178.5	80.33	0.01	160.65	0.01							Fee Schedule		132.09							Fee Schedule																				21.37							Fee Schedule		160.65							Fee Schedule		24.58							Fee Schedule		19.88							Fee Schedule											24.58							Fee Schedule		19.88							Fee Schedule		
EPICORD EX SKIN SUB 2CM X 3CM EX-5230	278	RC	Q4187	CPT				Both			695	312.75	130.95	625.5		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	514.3							Fee Schedule		130.95							Fee Schedule																				625.5							Fee Schedule																																															
EPICORD SKIN SUB 1CM X 2CM SHEET EC-5120	278	RC	Q4187	CPT				Both			453	203.85	118.24	407.7		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	335.22							Fee Schedule		130.95							Fee Schedule											127.14							Fee Schedule		407.7							Fee Schedule		146.21							Fee Schedule		118.24							Fee Schedule											146.21							Fee Schedule		118.24							Fee Schedule		
EPICORD SKIN SUB 2CM X 3CM SHEET EC-5230	278	RC	Q4187	CPT				Both			653	293.85	118.24	587.7		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	483.22							Fee Schedule		130.95							Fee Schedule											127.14							Fee Schedule		587.7							Fee Schedule		146.21							Fee Schedule		118.24							Fee Schedule											146.21							Fee Schedule		118.24							Fee Schedule		
EPIDERMAL GROWTH FACTOR RECEPTOR 16460	310	RC	81235	CPT				Both			1102.5	496.13	118.24	992.25	233.7							Fee Schedule		324.58							Fee Schedule		334.32							Fee Schedule		324.58							Fee Schedule		127.14							Fee Schedule		992.25							Fee Schedule		146.21							Fee Schedule		118.24							Fee Schedule											146.21							Fee Schedule		118.24							Fee Schedule		
EPIDURAL CATHETER	272	RC						Both			26.25	11.81	11.81	373.27	17.06							Fee Schedule		19.43							Fee Schedule																				324.58							Fee Schedule		23.63							Fee Schedule		373.27							Fee Schedule		301.86							Fee Schedule											373.27							Fee Schedule		301.86							Fee Schedule		
EPIDURAL NEEDLE 18GX31/2  332200	272	RC						Both			5.25	2.36	2.36	4.73	3.41							Fee Schedule		3.89							Fee Schedule																													4.73							Fee Schedule																																															
EPIDURAL NEEDLE 20G 3077V2	272	RC						Both			18	8.1	8.1	16.2	11.7							Fee Schedule		13.32							Fee Schedule																													16.2							Fee Schedule																																															
EPIDURAL TRAY CE17TKFCPS	272	RC						Both			69	31.05	31.05	62.1	44.85							Fee Schedule		51.06							Fee Schedule																													62.1							Fee Schedule																																															
EPIDURAL TRAY CE18TKY SAFETY	272	RC						Both			75	33.75	33.75	67.5	48.75							Fee Schedule		55.5							Fee Schedule																													67.5							Fee Schedule																																															
EPIDURAL TRAY SJ -05501	272	RC						Both			121.8	54.81	54.81	109.62	79.17							Fee Schedule		90.13							Fee Schedule																													109.62							Fee Schedule																																															
EPIDURAL TRAYS S25PTK	272	RC						Both			95.55	43	43	86	62.11							Fee Schedule		70.71							Fee Schedule																													86							Fee Schedule																																															
EPIFIX 4CMX4.5CM ES-4400	278	RC	Q4186	CPT				Both			377	169.65	130.95	339.3		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	278.98							Fee Schedule		130.95							Fee Schedule																				339.3							Fee Schedule																																															
EPIFIX MESH 3.5CMX3.5CM ES-3300	278	RC	Q4186	CPT				Both			469	211.05	118.24	422.1		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	347.06							Fee Schedule		130.95							Fee Schedule											127.14							Fee Schedule		422.1							Fee Schedule		146.21							Fee Schedule		118.24							Fee Schedule											146.21							Fee Schedule		118.24							Fee Schedule		
EPIFIX SKIN SUB 18MM DISK #GS-5180	278	RC	Q4186	CPT				Both			686	308.7	118.24	617.4		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	507.64							Fee Schedule		130.95							Fee Schedule											127.14							Fee Schedule		617.4							Fee Schedule		146.21							Fee Schedule		118.24							Fee Schedule											146.21							Fee Schedule		118.24							Fee Schedule		
EPIFIX SKIN SUB 2CM X 2CM SHEET #GS-5220	278	RC	Q4186	CPT				Both			740	333	118.24	666		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	547.6							Fee Schedule		130.95							Fee Schedule											127.14							Fee Schedule		666							Fee Schedule		146.21							Fee Schedule		118.24							Fee Schedule											146.21							Fee Schedule		118.24							Fee Schedule		
EPIFIX SKIN SUB 2CM X 3CM SHEET #GS-5230	278	RC	Q4186	CPT				Both			598	269.1	118.24	538.2		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	442.52							Fee Schedule		130.95							Fee Schedule											127.14							Fee Schedule		538.2							Fee Schedule		146.21							Fee Schedule		118.24							Fee Schedule											146.21							Fee Schedule		118.24							Fee Schedule		
EPIFIX SKIN SUB 2CMX3CM MESH #ES-2300	636	RC	Q4186	CPT				Both			728	327.6	118.24	655.2		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	538.72							Fee Schedule		130.95							Fee Schedule											127.14							Fee Schedule		655.2							Fee Schedule		146.21							Fee Schedule		118.24							Fee Schedule											146.21							Fee Schedule		118.24							Fee Schedule		
EPILOCK DRSG EASH	272	RC						Both			15.75	7.09	7.09	146.21	10.24							Fee Schedule		11.66							Fee Schedule																				127.14							Fee Schedule		14.18							Fee Schedule		146.21							Fee Schedule		118.24							Fee Schedule											146.21							Fee Schedule		118.24							Fee Schedule		
EPINEPHrine 1 MG/ML AMP	636	RC	J0166	CPT				Both			55.65	25.04	0.69	50.09		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	41.18							Fee Schedule		0.69							Fee Schedule																				50.09							Fee Schedule																																															
EPINEPHrine 1MG/10 ML SYRINGE	636	RC	J0168	CPT				Both			18.9	8.51	0.62	17.01		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	13.99							Fee Schedule		2.63							Fee Schedule											0.67							Fee Schedule		17.01							Fee Schedule		0.77							Fee Schedule		0.62							Fee Schedule											0.77							Fee Schedule		0.62							Fee Schedule		
EPINEPHrine 1MG/NS 250ML DRIP	636	RC	J0166	CPT				Both			27.3	12.29	0.69	24.57		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	20.2							Fee Schedule		0.69							Fee Schedule											2.56							Fee Schedule		24.57							Fee Schedule		2.94							Fee Schedule		2.38							Fee Schedule											2.94							Fee Schedule		2.38							Fee Schedule		
EPINEPHRINE PLASMA 37560	301	RC	82542	CPT				Both			50.4	22.68	0.62	45.36	17.34							Fee Schedule		24.09							Fee Schedule		24.81							Fee Schedule		24.09							Fee Schedule		0.67							Fee Schedule		45.36							Fee Schedule		0.77							Fee Schedule		0.62							Fee Schedule		24.09							Fee Schedule		0.77							Fee Schedule		0.62							Fee Schedule		
EPIPEN 0.3 MG (ADULT) INJECTION	636	RC	J0165	CPT				Both			766.5	344.93	0.24	689.85		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	567.21							Fee Schedule		0.24							Fee Schedule											24.09							Fee Schedule		689.85							Fee Schedule		27.7							Fee Schedule		22.4							Fee Schedule											27.7							Fee Schedule		22.4							Fee Schedule		
EPIPEN JR 0.15 MG INJECTION	636	RC	J0165	CPT				Both			766.5	344.93	0.22	689.85		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	567.21							Fee Schedule		0.24							Fee Schedule											0.23							Fee Schedule		689.85							Fee Schedule		0.27							Fee Schedule		0.22							Fee Schedule											0.27							Fee Schedule		0.22							Fee Schedule		
EPIVIR 150 MG TABLET UD	250	RC	A9270	CPT				Both			13.65	6.14	0.01	12.29	0.01							Fee Schedule		10.1							Fee Schedule																				0.23							Fee Schedule		12.29							Fee Schedule		0.27							Fee Schedule		0.22							Fee Schedule											0.27							Fee Schedule		0.22							Fee Schedule		
EPLERENONE (INSPRA)  25 MG TABLET UD	250	RC	A9270	CPT				Both			11.81	5.31	0.01	10.63	0.01							Fee Schedule		8.74							Fee Schedule																													10.63							Fee Schedule																																															
EPSOM SALT 4 OZ	250	RC	A9270	CPT				Both			4.2	1.89	0.01	3.78	0.01							Fee Schedule		3.11							Fee Schedule																													3.78							Fee Schedule																																															
ER CRITICAL CARE +30	450	RC	99292	CPT				Outpatient			254.1	114.35	104.52	300	121.79							Fee Schedule	Not separately reimbursed								Other	No Additional Reimbursement 	104.52							Fee Schedule		145							Fee Schedule		104.52							Fee Schedule		228.69							Fee Schedule									Other	No Additional Reimbursement	300							Case Rate									Other	No Additional Reimbursement								Other	No Additional Reimbursement								Other	No Additional Reimbursement	
ER CRITICAL CARE 1ST	450	RC	99291	CPT				Outpatient			3885	1748.25	243.15	7957	243.15							Fee Schedule	Not separately reimbursed								Other	No Additional Reimbursement 	766.03							Fee Schedule		460							Fee Schedule		766.03							Fee Schedule		3496.5							Fee Schedule		765.7							Fee Schedule		300							Case Rate		7957							Case Rate		765.7							Fee Schedule		1166							Case Rate		
ERCP	320	RC	74328	CPT				Both			451.5	203.18	67.25	406.35	67.25							Fee Schedule		119.83							Fee Schedule											89.02							Fee Schedule											406.35							Fee Schedule																				318							Per Diem																				
ERGOLOID MESYLATE 1 MG TABLET UD	250	RC	A9270	CPT				Both			4.2	1.89	0.01	3.78	0.01							Fee Schedule		3.11							Fee Schedule																													3.78							Fee Schedule																																															
ERTAPENEM (INVANZ) 1GM/NS 50ML IVPB	636	RC	J1335	CPT				Both			144	64.8	6.95	129.6		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	106.56							Fee Schedule		6.95							Fee Schedule																				129.6							Fee Schedule																																															
ERTAPENEM (INVANZ) 500MG/NS 50ML IVPB	636	RC	J1335	CPT				Both			288	129.6	6.28	259.2		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	213.12							Fee Schedule		6.95							Fee Schedule											6.75							Fee Schedule		259.2							Fee Schedule		7.76							Fee Schedule		6.28							Fee Schedule											7.76							Fee Schedule		6.28							Fee Schedule		
ERTAPENEM 1GM (INVANZ)  VIAL	636	RC	J1335	CPT				Both			144	64.8	6.28	129.6		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	106.56							Fee Schedule		6.95							Fee Schedule											6.75							Fee Schedule		129.6							Fee Schedule		7.76							Fee Schedule		6.28							Fee Schedule											7.76							Fee Schedule		6.28							Fee Schedule		
ERTAPENEM SODIUM 1 GRAM	250	RC	J1335	CPT				Both			2009.7	904.37	6.28	1808.73	38.7							Fee Schedule		1487.18							Fee Schedule		6.95							Fee Schedule											6.75							Fee Schedule		1808.73							Fee Schedule		7.76							Fee Schedule		6.28							Fee Schedule											7.76							Fee Schedule		6.28							Fee Schedule		
ERYC 250 MG CAPSULE UD	250	RC	A9270	CPT				Both			5.25	2.36	0.01	7.76	0.01							Fee Schedule		3.89							Fee Schedule																				6.75							Fee Schedule		4.73							Fee Schedule		7.76							Fee Schedule		6.28							Fee Schedule											7.76							Fee Schedule		6.28							Fee Schedule		
ERYTHRO ETHYL SUCC 400 MG/5ML ORAL SUSP	250	RC	A9270	CPT				Both			4.73	2.13	0.01	4.26	0.01							Fee Schedule		3.5							Fee Schedule																													4.26							Fee Schedule																																															
ERYTHROCIN 500 MG ADD-VANTAGE VIAL	636	RC	J1364	CPT				Both			34.65	15.59	8.34	177.65		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	25.64							Fee Schedule		177.65							Fee Schedule		8.34							Fee Schedule											31.19							Fee Schedule																																															
ERYTHROMYCIN  500MG VIAL	636	RC	J1364	CPT				Both			304.32	136.94	8.34	273.89		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	225.2							Fee Schedule		177.65							Fee Schedule		8.34							Fee Schedule		172.48							Fee Schedule		273.89							Fee Schedule		198.35							Fee Schedule		160.41							Fee Schedule											198.35							Fee Schedule		160.41							Fee Schedule		
ERYTHROMYCIN 200 MG/5 ML- 100ML	250	RC	A9270	CPT				Both			948.15	426.67	0.01	853.34	0.01							Fee Schedule		701.63							Fee Schedule																				172.48							Fee Schedule		853.34							Fee Schedule		198.35							Fee Schedule		160.41							Fee Schedule											198.35							Fee Schedule		160.41							Fee Schedule		
ERYTHROMYCIN 250 MG TABLET UD	250	RC	A9270	CPT				Both			36.75	16.54	0.01	33.08	0.01							Fee Schedule		27.2							Fee Schedule																													33.08							Fee Schedule																																															
ERYTHROMYCIN 500MG	636	RC	J1364	CPT				Both			39.2	17.64	8.34	177.65		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	29.01							Fee Schedule		177.65							Fee Schedule		8.34							Fee Schedule											35.28							Fee Schedule																																															
ERYTHROMYCIN 500MG /NS 100ML IVPB	636	RC	J1364	CPT				Both			262.5	118.13	8.34	236.25		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	194.25							Fee Schedule		177.65							Fee Schedule		8.34							Fee Schedule		172.48							Fee Schedule		236.25							Fee Schedule		198.35							Fee Schedule		160.41							Fee Schedule											198.35							Fee Schedule		160.41							Fee Schedule		
ERYTHROMYCIN ESTOLATE 125 MG/5ML UD	250	RC	A9270	CPT				Both			14.7	6.62	0.01	198.35	0.01							Fee Schedule		10.88							Fee Schedule																				172.48							Fee Schedule		13.23							Fee Schedule		198.35							Fee Schedule		160.41							Fee Schedule											198.35							Fee Schedule		160.41							Fee Schedule		
ERYTHROMYCIN OPTH 0.5% UD	250	RC	A9270	CPT				Both			32.55	14.65	0.01	29.3	0.01							Fee Schedule		24.09							Fee Schedule																													29.3							Fee Schedule																																															
ERYTHROMYCN OPTH OINT 1 GM (0.5%)	250	RC	A9270	CPT				Both			39.12	17.6	0.01	35.21	0.01							Fee Schedule		28.95							Fee Schedule																													35.21							Fee Schedule																																															
ERYTHROPOIETIN 427 SERUM	301	RC	82668	CPT				Both			165.9	74.66	16.7	149.31	16.7							Fee Schedule		20.88							Fee Schedule		19.35							Fee Schedule		18.79							Fee Schedule											149.31							Fee Schedule																				18.79							Fee Schedule																				
ESCITALOPRAM (LEXAPRO) 10MG  TABLET	250	RC	A9270	CPT				Both			7.35	3.31	0.01	21.61	0.01							Fee Schedule		5.44							Fee Schedule																				18.79							Fee Schedule		6.62							Fee Schedule		21.61							Fee Schedule		17.47							Fee Schedule											21.61							Fee Schedule		17.47							Fee Schedule		
ESMARK BANDAGES 6X9 DYNJ05918	272	RC						Both			11	4.95	4.95	9.9	7.15							Fee Schedule		8.14							Fee Schedule																													9.9							Fee Schedule																																															
ESMARK STERILE 4X9 #30-196	272	RC						Both			4	1.8	1.8	3.6	2.6							Fee Schedule		2.96							Fee Schedule																													3.6							Fee Schedule																																															
ESMARK STERILE 6X9 #30-198	272	RC						Both			7	3.15	3.15	6.3	4.55							Fee Schedule		5.18							Fee Schedule																													6.3							Fee Schedule																																															
ESMOLOL 2500MG/NS 250ML PREMIX	636	RC	J1805	CPT				Both			1768.2	795.69	0.24	1591.38		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1308.47							Fee Schedule		0.24							Fee Schedule																				1591.38							Fee Schedule																																															
ESMOLOL INJECTION 10MG/ML-10ML VIAL	250	RC	J1805	CPT				Both			135.45	60.95	0.21	121.91	88.04							Fee Schedule		100.23							Fee Schedule		0.24							Fee Schedule											0.23							Fee Schedule		121.91							Fee Schedule		0.26							Fee Schedule		0.21							Fee Schedule											0.26							Fee Schedule		0.21							Fee Schedule		
ESOPH TMP/STH PROBE 12FR	272	RC						Both			29.4	13.23	0.21	26.46	19.11							Fee Schedule		21.76							Fee Schedule																				0.23							Fee Schedule		26.46							Fee Schedule		0.26							Fee Schedule		0.21							Fee Schedule											0.26							Fee Schedule		0.21							Fee Schedule		
ESOPH TMP/STH PROBE 18FR ES-81-050418	272	RC						Both			29.4	13.23	13.23	26.46	19.11							Fee Schedule		21.76							Fee Schedule																													26.46							Fee Schedule																																															
ESOPHAGEAL AIRWAY	272	RC						Both			4.2	1.89	1.89	3.78	2.73							Fee Schedule		3.11							Fee Schedule																													3.78							Fee Schedule																																															
ESOPHAGEAL OVERTUBE 00711146	272	RC						Both			518	233.1	233.1	466.2	336.7							Fee Schedule		383.32							Fee Schedule																													466.2							Fee Schedule																																															
ESOPHAGEAL REMOVER & SUCTION ET2000	270	RC						Both			792	356.4	356.4	712.8	514.8							Fee Schedule		586.08							Fee Schedule																													712.8							Fee Schedule																																															
ESOPHAGEAL STENT POLYFLEX #M00514310	278	RC	C1874	CPT				Both			7182	3231.9	3231.9	6463.8		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	5314.68							Fee Schedule																													6463.8							Fee Schedule																																															
ESOPHAGEAL TUBE 0092100 (BARD UROLOGICAL	271	RC						Both			897.75	403.99	403.99	807.98	583.54							Fee Schedule		664.34							Fee Schedule																													807.98							Fee Schedule																																															
OTHER CIRCULATORY SYSTEM DIAGNOSES WITH CC					315	DRG		Inpatient			23025.81	10361.62	10361.62	10361.62							0		No services performed during 15 month lookback period. 				3615.56	3615.56	3615.56	1 through 10									0		No services performed during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback				7900.13	7900.13	7900.13	1 through 10									0		No services provided during 15 month lookback period	
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITH MCC"					326	DRG		Inpatient			149912.93	67460.82	67460.82	67460.82							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period							0		No services provided during 15 month lookback period				31798.27	31798.27	31798.27	1 through 10									0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period	
ESTRADERM 0.05 MG/24 HR TRASDERM PATCH	250	RC	A9270	CPT				Both			16.54	7.44	0.01	14.89	0.01							Fee Schedule		12.24							Fee Schedule																													14.89							Fee Schedule																																															
ESTRADERM 0.1 MG/24 HR TRANSDERM PATCH	250	RC	A9270	CPT				Both			17.85	8.03	0.01	16.07	0.01							Fee Schedule		13.21							Fee Schedule																													16.07							Fee Schedule																																															
ESTRADIOL 0.5MG (ESTRACE) TABLET	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
ESTRADIOL 1MG (ESTRACE) TABLET	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
ESTRADIOL 4021 SERUM RT	301	RC	82670	CPT				Both			159.6	71.82	24.83	143.64	24.83							Fee Schedule		31.04							Fee Schedule		28.78							Fee Schedule		27.94							Fee Schedule											143.64							Fee Schedule																				27.94							Fee Schedule																				
ESTROGEN FRACTIONATED 36742 SERUM FRZ	301	RC	82671	CPT				Both			356.79	160.56	25.98	321.11	28.71							Fee Schedule		35.89							Fee Schedule		33.27							Fee Schedule		32.3							Fee Schedule		27.94							Fee Schedule		321.11							Fee Schedule		32.13							Fee Schedule		25.98							Fee Schedule		32.3							Fee Schedule		32.13							Fee Schedule		25.98							Fee Schedule		
"ESTROGEN, TOTAL, SERUM 439"	301	RC	82672	CPT				Both			164.21	73.89	19.28	147.79	19.28							Fee Schedule		24.11							Fee Schedule		22.35							Fee Schedule		21.7							Fee Schedule		32.3							Fee Schedule		147.79							Fee Schedule		37.15							Fee Schedule		30.04							Fee Schedule		21.7							Fee Schedule		37.15							Fee Schedule		30.04							Fee Schedule		
ESTROIL 34883	301	RC	82677	CPT				Both			131.25	59.06	20.18	118.13	21.49							Fee Schedule		26.87							Fee Schedule		24.91							Fee Schedule		24.18							Fee Schedule		21.7							Fee Schedule		118.13							Fee Schedule		24.96							Fee Schedule		20.18							Fee Schedule		24.18							Fee Schedule		24.96							Fee Schedule		20.18							Fee Schedule		
ESTRONE 23244 SERUM	301	RC	82679	CPT				Both			143.85	64.73	22.18	129.47	22.18							Fee Schedule		27.73							Fee Schedule		25.7							Fee Schedule		24.95							Fee Schedule		24.18							Fee Schedule		129.47							Fee Schedule		27.81							Fee Schedule		22.49							Fee Schedule		24.95							Fee Schedule		27.81							Fee Schedule		22.49							Fee Schedule		
ET TUBE FASTENER 9799	270	RC	A4625	CPT				Both			27	12.15	5.3	28.69	5.3							Fee Schedule		19.98							Fee Schedule		8.64							Fee Schedule		6.62							Fee Schedule		24.95							Fee Schedule		24.3							Fee Schedule		28.69							Fee Schedule		23.2							Fee Schedule											28.69							Fee Schedule		23.2							Fee Schedule		
ETHAMBUTOL 100 MG TABLET UD	250	RC	A9270	CPT				Both			6.3	2.84	0.01	9.65	0.01							Fee Schedule		4.66							Fee Schedule																				8.39							Fee Schedule		5.67							Fee Schedule		9.65							Fee Schedule		7.8							Fee Schedule											9.65							Fee Schedule		7.8							Fee Schedule		
ETHAMBUTOL 400 MG (MYAMBUTOL) TABLET UD	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
ETHCHLORVYNOL 722 SERUM	301	RC	80307	CPT				Both			73.5	33.08	33.08	66.15	51.72							Fee Schedule		64.65							Fee Schedule		64							Fee Schedule		62.14							Fee Schedule											66.15							Fee Schedule																				62.14							Fee Schedule																				
ETHEZYME DEBRIDING OINTMENT-30GM	250	RC	A9270	CPT				Both			156.71	70.52	0.01	141.04	0.01							Fee Schedule		115.97							Fee Schedule																				62.14							Fee Schedule		141.04							Fee Schedule		71.46							Fee Schedule		57.79							Fee Schedule											71.46							Fee Schedule		57.79							Fee Schedule		
ETHIBAND #1 X518H	272	RC						Both			13.65	6.14	6.14	12.29	8.87							Fee Schedule		10.1							Fee Schedule																													12.29							Fee Schedule																																															
ETHIBOND 0  X444H	272	RC						Both			8	3.6	3.6	7.2	5.2							Fee Schedule		5.92							Fee Schedule																													7.2							Fee Schedule																																															
ETHIBOND 0  X834H	272	RC						Both			7	3.15	3.15	6.3	4.55							Fee Schedule		5.18							Fee Schedule																													6.3							Fee Schedule																																															
ETHIBOND 0 X424H	272	RC						Both			6	2.7	2.7	5.4	3.9							Fee Schedule		4.44							Fee Schedule																													5.4							Fee Schedule																																															
ETHIBOND 0 X444H	272	RC						Both			9	4.05	4.05	8.1	5.85							Fee Schedule		6.66							Fee Schedule																													8.1							Fee Schedule																																															
ETHIBOND 2 MX69G	272	RC						Both			50	22.5	22.5	45	32.5							Fee Schedule		37							Fee Schedule																													45							Fee Schedule																																															
ETHIBOND 2.0 X997G	272	RC						Both			58	26.1	26.1	52.2	37.7							Fee Schedule		42.92							Fee Schedule																													52.2							Fee Schedule																																															
ETHIBOND 4-0  X871H	272	RC						Both			5.78	2.6	2.6	5.2	3.76							Fee Schedule		4.28							Fee Schedule																													5.2							Fee Schedule																																															
ETHIBOND 5 MB46G	272	RC						Both			19	8.55	8.55	17.1	12.35							Fee Schedule		14.06							Fee Schedule																													17.1							Fee Schedule																																															
ETHIBOND 5-0  B499T	272	RC						Both			28	12.6	12.6	25.2	18.2							Fee Schedule		20.72							Fee Schedule																													25.2							Fee Schedule																																															
ETHIBOND O CX21D	272	RC						Both			38.85	17.48	17.48	34.97	25.25							Fee Schedule		28.75							Fee Schedule																													34.97							Fee Schedule																																															
ETHIBOND SUTURE ASSIST RELOAD SW120	272	RC						Both			90.3	40.64	40.64	81.27	58.7							Fee Schedule		66.82							Fee Schedule																													81.27							Fee Schedule																																															
ETHIBOND X538H	272	RC						Both			13.65	6.14	6.14	12.29	8.87							Fee Schedule		10.1							Fee Schedule																													12.29							Fee Schedule																																															
ETHICON 12MM TROCAR 512HT	272	RC						Both			442.05	198.92	198.92	397.85	287.33							Fee Schedule		327.12							Fee Schedule																													397.85							Fee Schedule																																															
ETHICON 12MM TROCAR 512S	272	RC						Both			202.65	91.19	91.19	182.39	131.72							Fee Schedule		149.96							Fee Schedule																													182.39							Fee Schedule																																															
ETHICON 12MM TROCAR LONG 512XD	272	RC						Both			388.5	174.83	174.83	349.65	252.53							Fee Schedule		287.49							Fee Schedule																													349.65							Fee Schedule																																															
ETHICON 2B12LT	272	RC						Both			143.85	64.73	64.73	129.47	93.5							Fee Schedule		106.45							Fee Schedule																													129.47							Fee Schedule																																															
ETHICON 2D5ST	272	RC						Both			141.75	63.79	63.79	127.58	92.14							Fee Schedule		104.9							Fee Schedule																													127.58							Fee Schedule																																															
ETHICON 4.0 1667G	272	RC						Both			13.65	6.14	6.14	12.29	8.87							Fee Schedule		10.1							Fee Schedule																													12.29							Fee Schedule																																															
ETHICON 5MM LONG TROCAR 355L	272	RC						Both			169.05	76.07	76.07	152.15	109.88							Fee Schedule		125.1							Fee Schedule																													152.15							Fee Schedule																																															
ETHICON 5MM TROCAR 355S	272	RC						Both			169.05	76.07	76.07	152.15	109.88							Fee Schedule		125.1							Fee Schedule																													152.15							Fee Schedule																																															
ETHICON ALLIS	272	RC						Both			456.75	205.54	205.54	411.08	296.89							Fee Schedule		338							Fee Schedule																													411.08							Fee Schedule																																															
ETHICON ARTIC. CUTTER # EC45A	272	RC						Both			848.4	381.78	381.78	763.56	551.46							Fee Schedule		627.82							Fee Schedule																													763.56							Fee Schedule																																															
ETHICON ARTICULATING CUTTER 6TB45	272	RC						Both			1375.5	618.98	618.98	1237.95	894.08							Fee Schedule		1017.87							Fee Schedule																													1237.95							Fee Schedule																																															
ETHICON ATW35	272	RC						Both			714	321.3	321.3	642.6	464.1							Fee Schedule		528.36							Fee Schedule																													642.6							Fee Schedule																																															
ETHICON BABCOCK GRASPER 10BB	272	RC						Both			241	108.45	108.45	216.9	156.65							Fee Schedule		178.34							Fee Schedule																													216.9							Fee Schedule																																															
ETHICON BLADELESS TROCAR 2B5LT	272	RC						Both			141.75	63.79	63.79	127.58	92.14							Fee Schedule		104.9							Fee Schedule																													127.58							Fee Schedule																																															
ETHICON BLADELESS TROCAR 2B5ST	272	RC						Both			141.75	63.79	63.79	127.58	92.14							Fee Schedule		104.9							Fee Schedule																													127.58							Fee Schedule																																															
ETHICON BLADELESS TROCAR 2CB5ST	272	RC						Both			78.75	35.44	35.44	70.88	51.19							Fee Schedule		58.28							Fee Schedule																													70.88							Fee Schedule																																															
ETHICON BLADELESS TROCAR B12LP	272	RC						Both			226.8	102.06	102.06	204.12	147.42							Fee Schedule		167.83							Fee Schedule																													204.12							Fee Schedule																																															
ETHICON BLADELESS TROCAR B5XT	272	RC						Both			126	56.7	56.7	113.4	81.9							Fee Schedule		93.24							Fee Schedule																													113.4							Fee Schedule																																															
ETHICON BLAKE  DRAIN 15FR 2229 J&J	272	RC						Both			292	131.4	131.4	262.8	189.8							Fee Schedule		216.08							Fee Schedule																													262.8							Fee Schedule																																															
ETHICON BLAKE SILICON DRAIN 10FR 2226	272	RC						Both			247	111.15	111.15	222.3	160.55							Fee Schedule		182.78							Fee Schedule																													222.3							Fee Schedule																																															
ETHICON BLAKE SILICON DRAIN 19FR 2231	272	RC						Both			239	107.55	107.55	215.1	155.35							Fee Schedule		176.86							Fee Schedule																													215.1							Fee Schedule																																															
ETHICON BLUE RELOAD GST45B   J&J	272	RC						Both			711.9	320.36	320.36	640.71	462.74							Fee Schedule		526.81							Fee Schedule																													640.71							Fee Schedule																																															
ETHICON BOWEL CLAMP 10MM	272	RC						Both			456.75	205.54	205.54	411.08	296.89							Fee Schedule		338							Fee Schedule																													411.08							Fee Schedule																																															
ETHICON BOWEL CLAMP 10MM BC10 (SENECA)	272	RC						Both			339.15	152.62	152.62	305.24	220.45							Fee Schedule		250.97							Fee Schedule																													305.24							Fee Schedule																																															
ETHICON CDH 29 CIRCULAR STAPLER	272	RC						Both			1100.4	495.18	495.18	990.36	715.26							Fee Schedule		814.3							Fee Schedule																													990.36							Fee Schedule																																															
ETHICON CHOLE KIT FDA 21	272	RC						Both			580.65	261.29	261.29	522.59	377.42							Fee Schedule		429.68							Fee Schedule																													522.59							Fee Schedule																																															
ETHICON CIRCULAR STAPLER #ECS21	272	RC						Both			1871.1	842	842	1683.99	1216.22							Fee Schedule		1384.61							Fee Schedule																													1683.99							Fee Schedule																																															
ETHICON CIRCULAR STAPLER ECS29B   J&J	272	RC						Both			1303	586.35	586.35	1172.7	846.95							Fee Schedule		964.22							Fee Schedule																													1172.7							Fee Schedule																																															
ETHICON CIRCULAR STAPLER ECS33B	272	RC						Both			1140	513	513	1026	741							Fee Schedule		843.6							Fee Schedule																													1026							Fee Schedule																																															
ETHICON CLIP APPLIER # MCS20	272	RC						Both			183.75	82.69	82.69	165.38	119.44							Fee Schedule		135.98							Fee Schedule																													165.38							Fee Schedule																																															
ETHICON CONTOR RELOAD GCR40G	272	RC						Both			850	382.5	382.5	765	552.5							Fee Schedule		629							Fee Schedule																													765							Fee Schedule																																															
ETHICON COUTOUR RELOAD GCR40G J&J	272	RC						Both			850	382.5	382.5	765	552.5							Fee Schedule		629							Fee Schedule																													765							Fee Schedule																																															
ETHICON CURVED CUTTER STAPLER #CS40G	272	RC						Both			1511	679.95	679.95	1359.9	982.15							Fee Schedule		1118.14							Fee Schedule																													1359.9							Fee Schedule																																															
ETHICON CURVED STAPLER  GCS40G  J&J	272	RC						Both			1511	679.95	679.95	1359.9	982.15							Fee Schedule		1118.14							Fee Schedule																													1359.9							Fee Schedule																																															
ETHICON CURVMICROSCISS.DCS12/NEW#5DCS	272	RC						Both			186.9	84.11	84.11	168.21	121.49							Fee Schedule		138.31							Fee Schedule																													168.21							Fee Schedule																																															
ETHICON CUT RELOAD TR45W *DISC->GST45W*	272	RC						Both			456	205.2	205.2	410.4	296.4							Fee Schedule		337.44							Fee Schedule																													410.4							Fee Schedule																																															
ETHICON CUTTER # EC60A	272	RC						Both			971.25	437.06	437.06	874.13	631.31							Fee Schedule		718.73							Fee Schedule																													874.13							Fee Schedule																																															
ETHICON CUTTER RELOAD CR40G	272	RC						Both			850	382.5	382.5	765	552.5							Fee Schedule		629							Fee Schedule																													765							Fee Schedule																																															
ETHICON DEXTRUS HAND PORT FLR02	272	RC						Both			153.3	68.99	68.99	137.97	99.65							Fee Schedule		113.44							Fee Schedule																													137.97							Fee Schedule																																															
ETHICON DUX HAL. # HAP02  ( J&J )	272	RC						Both			1959	881.55	881.55	1763.1	1273.35							Fee Schedule		1449.66							Fee Schedule																													1763.1							Fee Schedule																																															
ETHICON ECHELON FLEX (PSE60A) PSEE60A	272	RC						Both			1113	500.85	500.85	1001.7	723.45							Fee Schedule		823.62							Fee Schedule																													1001.7							Fee Schedule																																															
ETHICON ECHELON RELOAD  GST60T  J&J	272	RC						Both			786	353.7	353.7	707.4	510.9							Fee Schedule		581.64							Fee Schedule																													707.4							Fee Schedule																																															
ETHICON ECHELON RELOAD (ECR60B) GST60B	272	RC						Both			786	353.7	353.7	707.4	510.9							Fee Schedule		581.64							Fee Schedule																													707.4							Fee Schedule																																															
ETHICON ECHELON RELOAD (ECR60W) GST60W	272	RC						Both			542.85	244.28	244.28	488.57	352.85							Fee Schedule		401.71							Fee Schedule																													488.57							Fee Schedule																																															
ETHICON ELC 60	272	RC						Both			1277.85	575.03	575.03	1150.07	830.6							Fee Schedule		945.61							Fee Schedule																													1150.07							Fee Schedule																																															
ETHICON ENDO STAPLER   CDH31P  J&J	272	RC						Both			1656	745.2	745.2	1490.4	1076.4							Fee Schedule		1225.44							Fee Schedule																													1490.4							Fee Schedule																																															
ETHICON ENDO STAPLER 29MM  CDH25P  J&J	272	RC						Both			1757	790.65	790.65	1581.3	1142.05							Fee Schedule		1300.18							Fee Schedule																													1581.3							Fee Schedule																																															
ETHICON ENDO STAPLER 29MM  CDH29P  J&J	272	RC						Both			1656	745.2	745.2	1490.4	1076.4							Fee Schedule		1225.44							Fee Schedule																													1490.4							Fee Schedule																																															
ETHICON ENDO STAPLER 29MM CURVED CDH29A	272	RC						Both			1151.85	518.33	518.33	1036.67	748.7							Fee Schedule		852.37							Fee Schedule																													1036.67							Fee Schedule																																															
ETHICON ENDOLOOP	272	RC						Both			93.45	42.05	42.05	84.11	60.74							Fee Schedule		69.15							Fee Schedule																													84.11							Fee Schedule																																															
ETHICON EXCEL MB46	272	RC						Both			53.55	24.1	24.1	48.2	34.81							Fee Schedule		39.63							Fee Schedule																													48.2							Fee Schedule																																															
ETHICON FOCUS  SHEAR HAR9F SUSTAINABILTY	272	RC						Both			1022	459.9	459.9	919.8	664.3							Fee Schedule		756.28							Fee Schedule																													919.8							Fee Schedule																																															
ETHICON GIA TSW 35	272	RC						Both			714	321.3	321.3	642.6	464.1							Fee Schedule		528.36							Fee Schedule																													642.6							Fee Schedule																																															
ETHICON GOLD RELOAD ECR45D (J&J)	272	RC						Both			369.6	166.32	166.32	332.64	240.24							Fee Schedule		273.5							Fee Schedule																													332.64							Fee Schedule																																															
ETHICON GREEN RELOAD (ECR45G) GST45G	272	RC						Both			727	327.15	327.15	654.3	472.55							Fee Schedule		537.98							Fee Schedule																													654.3							Fee Schedule																																															
ETHICON HAND ACCESS PORT HAP02 (J&J)	272	RC						Both			1491	670.95	670.95	1341.9	969.15							Fee Schedule		1103.34							Fee Schedule																													1341.9							Fee Schedule																																															
ETHICON HARMONIC  HAR36	272	RC						Both			975	438.75	438.75	877.5	633.75							Fee Schedule		721.5							Fee Schedule																													877.5							Fee Schedule																																															
ETHICON HARMONIC ACE36P (J&J)	272	RC						Both			1831.2	824.04	824.04	1648.08	1190.28							Fee Schedule		1355.09							Fee Schedule																													1648.08							Fee Schedule																																															
ETHICON HEMORRHOID STAPLER #PPH03 *DISC*	272	RC						Both			1252.65	563.69	563.69	1127.39	814.22							Fee Schedule		926.96							Fee Schedule																													1127.39							Fee Schedule																																															
ETHICON HERNIA CLIPS	272	RC						Both			843.15	379.42	379.42	758.84	548.05							Fee Schedule		623.93							Fee Schedule																													758.84							Fee Schedule																																															
ETHICON HERNIA MESH UMM3	278	RC	C1781	CPT				Both			840	378	378	756		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	621.6							Fee Schedule																													756							Fee Schedule																																															
ETHICON HERNIA MESH UMR3	278	RC	C1781	CPT				Both			651	292.95	292.95	585.9		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	481.74							Fee Schedule																													585.9							Fee Schedule																																															
ETHICON ILS #EC521	272	RC						Both			1218	548.1	548.1	1096.2	791.7							Fee Schedule		901.32							Fee Schedule																													1096.2							Fee Schedule																																															
ETHICON IRR/SUCTION ERS11	272	RC						Both			221.55	99.7	99.7	199.4	144.01							Fee Schedule		163.95							Fee Schedule																													199.4							Fee Schedule																																															
ETHICON IRRIGATION TUBING EPT03	272	RC						Both			112.35	50.56	50.56	101.12	73.03							Fee Schedule		83.14							Fee Schedule																													101.12							Fee Schedule																																															
ETHICON IRRIGATOR  EPS 10	272	RC						Both			169.05	76.07	76.07	152.15	109.88							Fee Schedule		125.1							Fee Schedule																													152.15							Fee Schedule																																															
ETHICON IRRIGATOR SUCTION EPS11	272	RC						Both			221.55	99.7	99.7	199.4	144.01							Fee Schedule		163.95							Fee Schedule																													199.4							Fee Schedule																																															
ETHICON LAP DISC LD111	272	RC						Both			1483.65	667.64	667.64	1335.29	964.37							Fee Schedule		1097.9							Fee Schedule																													1335.29							Fee Schedule																																															
ETHICON LAP DISC LD112	272	RC						Both			1770.3	796.64	796.64	1593.27	1150.7							Fee Schedule		1310.02							Fee Schedule																													1593.27							Fee Schedule																																															
ETHICON LIGACLIP CLIP APPLIER 10MM ER320	272	RC						Both			301	135.45	135.45	270.9	195.65							Fee Schedule		222.74							Fee Schedule																													270.9							Fee Schedule																																															
ETHICON LIGACLIP LT100	272	RC						Both			8	3.6	3.6	7.2	5.2							Fee Schedule		5.92							Fee Schedule																													7.2							Fee Schedule																																															
ETHICON LIGACLIP LT100	272	RC						Both			8	3.6	3.6	7.2	5.2							Fee Schedule		5.92							Fee Schedule																													7.2							Fee Schedule																																															
ETHICON LIGACLIP LT200	272	RC						Both			10	4.5	4.5	9	6.5							Fee Schedule		7.4							Fee Schedule																													9							Fee Schedule																																															
ETHICON LIGACLIP LT300	272	RC						Both			13	5.85	5.85	11.7	8.45							Fee Schedule		9.62							Fee Schedule																													11.7							Fee Schedule																																															
ETHICON LIGACLIP LT400	272	RC						Both			19	8.55	8.55	17.1	12.35							Fee Schedule		14.06							Fee Schedule																													17.1							Fee Schedule																																															
ETHICON LIGACLIP RELOAD TIR20	272	RC						Both			113.4	51.03	51.03	102.06	73.71							Fee Schedule		83.92							Fee Schedule																													102.06							Fee Schedule																																															
ETHICON LIGACLIP TIM120 (SENECA MEDICAL)	272	RC						Both			225.75	101.59	101.59	203.18	146.74							Fee Schedule		167.06							Fee Schedule																													203.18							Fee Schedule																																															
ETHICON LIGAMAX CLIP APPLIER 5MM #EL5ML	272	RC						Both			607.95	273.58	273.58	547.16	395.17							Fee Schedule		449.88							Fee Schedule																													547.16							Fee Schedule																																															
ETHICON LIGAMAX RELOADS EL5ML	272	RC						Both			547	246.15	246.15	492.3	355.55							Fee Schedule		404.78							Fee Schedule																													492.3							Fee Schedule																																															
ETHICON LINE CUT ATS45 *DISC SEE ECH45S*	272	RC						Both			1747	786.15	786.15	1572.3	1135.55							Fee Schedule		1292.78							Fee Schedule																													1572.3							Fee Schedule																																															
ETHICON LINEAR CUTTER TSG45 (SENECA MEDI	272	RC						Both			854.7	384.62	384.62	769.23	555.56							Fee Schedule		632.48							Fee Schedule																													769.23							Fee Schedule																																															
ETHICON LINEAR CUTTER TSW45	272	RC						Both			699.3	314.69	314.69	629.37	454.55							Fee Schedule		517.48							Fee Schedule																													629.37							Fee Schedule																																															
ETHICON MERSILENE 4-0 1762G	272	RC						Both			54	24.3	24.3	48.6	35.1							Fee Schedule		39.96							Fee Schedule																													48.6							Fee Schedule																																															
ETHICON MONOFIL. SUTURE #PDSZ8806	272	RC						Both			24.15	10.87	10.87	21.74	15.7							Fee Schedule		17.87							Fee Schedule																													21.74							Fee Schedule																																															
ETHICON MULTI FEED STAPLER EMS	272	RC						Both			575.4	258.93	258.93	517.86	374.01							Fee Schedule		425.8							Fee Schedule																													517.86							Fee Schedule																																															
ETHICON NSEAL # X22L	272	RC						Both			1984.5	893.03	893.03	1786.05	1289.93							Fee Schedule		1468.53							Fee Schedule																													1786.05							Fee Schedule																																															
ETHICON NSEALX22L *DISC.* NSLX120L-NEW	272	RC						Both			2668.05	1200.62	1200.62	2401.25	1734.23							Fee Schedule		1974.36							Fee Schedule																													2401.25							Fee Schedule																																															
ETHICON PCEE45A  J&J	272	RC						Both			1346	605.7	605.7	1211.4	874.9							Fee Schedule		996.04							Fee Schedule																													1211.4							Fee Schedule																																															
ETHICON PISTOL GRIP FIX HEAD PXW35	272	RC						Both			34.65	15.59	15.59	31.19	22.52							Fee Schedule		25.64							Fee Schedule																													31.19							Fee Schedule																																															
ETHICON PISTOL GRIP HANDLE EPH01	272	RC						Both			247.8	111.51	111.51	223.02	161.07							Fee Schedule		183.37							Fee Schedule																													223.02							Fee Schedule																																															
ETHICON PROXIMATE CDH-21	272	RC						Both			834.75	375.64	375.64	751.28	542.59							Fee Schedule		617.72							Fee Schedule																													751.28							Fee Schedule																																															
ETHICON PROXIMATE CDH-25	272	RC						Both			972.3	437.54	437.54	875.07	632							Fee Schedule		719.5							Fee Schedule																													875.07							Fee Schedule																																															
ETHICON PROXIMATE CDH-29	272	RC						Both			972.3	437.54	437.54	875.07	632							Fee Schedule		719.5							Fee Schedule																													875.07							Fee Schedule																																															
ETHICON PROXIMATE CUTTER TLC75  J&J	272	RC						Both			525	236.25	236.25	472.5	341.25							Fee Schedule		388.5							Fee Schedule																													472.5							Fee Schedule																																															
ETHICON PROXIMATE RELOAD TCR75  J&J	272	RC						Both			271.95	122.38	122.38	244.76	176.77							Fee Schedule		201.24							Fee Schedule																													244.76							Fee Schedule																																															
ETHICON PROXIMATE RELOADS XR30B	272	RC						Both			151	67.95	67.95	135.9	98.15							Fee Schedule		111.74							Fee Schedule																													135.9							Fee Schedule																																															
ETHICON PROXIMATE RELOADS XR60B	272	RC						Both			132.3	59.54	59.54	119.07	86							Fee Schedule		97.9							Fee Schedule																													119.07							Fee Schedule																																															
ETHICON PROXIMATE RELOADS XR60B	272	RC						Both			178.5	80.33	80.33	160.65	116.03							Fee Schedule		132.09							Fee Schedule																													160.65							Fee Schedule																																															
ETHICON PROXIMATE RELOADS XR60G	272	RC						Both			169	76.05	76.05	152.1	109.85							Fee Schedule		125.06							Fee Schedule																													152.1							Fee Schedule																																															
ETHICON PROXIMATE STAPLER TX60B  J&J	272	RC						Both			337	151.65	151.65	303.3	219.05							Fee Schedule		249.38							Fee Schedule																													303.3							Fee Schedule																																															
ETHICON PROXMATE STAPLER TX60G	272	RC						Both			344.4	154.98	154.98	309.96	223.86							Fee Schedule		254.86							Fee Schedule																													309.96							Fee Schedule																																															
ETHICON REDUCER MS512	272	RC						Both			169.05	76.07	76.07	152.15	109.88							Fee Schedule		125.1							Fee Schedule																													152.15							Fee Schedule																																															
ETHICON RELOAD #GST60G  J&J	272	RC						Both			770.7	346.82	346.82	693.63	500.96							Fee Schedule		570.32							Fee Schedule																													693.63							Fee Schedule																																															
ETHICON RELOAD #TCR55	272	RC						Both			189	85.05	85.05	170.1	122.85							Fee Schedule		139.86							Fee Schedule																													170.1							Fee Schedule																																															
ETHICON RELOAD 6R45B *DISC SEE GST45B*	272	RC						Both			459	206.55	206.55	413.1	298.35							Fee Schedule		339.66							Fee Schedule																													413.1							Fee Schedule																																															
ETHICON RELOAD STAPLE #TRH90 *DISC.*	272	RC						Both			153.3	68.99	68.99	137.97	99.65							Fee Schedule		113.44							Fee Schedule																													137.97							Fee Schedule																																															
ETHICON RELOAD TCR10	272	RC						Both			426	191.7	191.7	383.4	276.9							Fee Schedule		315.24							Fee Schedule																													383.4							Fee Schedule																																															
ETHICON RELOAD TR35B	272	RC						Both			308.7	138.92	138.92	277.83	200.66							Fee Schedule		228.44							Fee Schedule																													277.83							Fee Schedule																																															
ETHICON RELOAD TR45B	272	RC						Both			320.25	144.11	144.11	288.23	208.16							Fee Schedule		236.99							Fee Schedule																													288.23							Fee Schedule																																															
ETHICON RELOAD TR45G  (SENECA MEDICAL)	272	RC						Both			318.15	143.17	143.17	286.34	206.8							Fee Schedule		235.43							Fee Schedule																													286.34							Fee Schedule																																															
ETHICON RELOADABLE STAPLER #TLH90 *DISC.	272	RC						Both			291.9	131.36	131.36	262.71	189.74							Fee Schedule		216.01							Fee Schedule																													262.71							Fee Schedule																																															
ETHICON RELOADS TL 55	272	RC						Both			307.65	138.44	138.44	276.89	199.97							Fee Schedule		227.66							Fee Schedule																													276.89							Fee Schedule																																															
ETHICON RETENTION SUTURE BRIDGE #RSB5	272	RC						Both			8.4	3.78	3.78	7.56	5.46							Fee Schedule		6.22							Fee Schedule																													7.56							Fee Schedule																																															
ETHICON RETRACTOR # FLR01  ( J&J )	272	RC						Both			189	85.05	85.05	170.1	122.85							Fee Schedule		139.86							Fee Schedule																													170.1							Fee Schedule																																															
ETHICON RIGHT ANGLE BRK 10	272	RC						Both			456.75	205.54	205.54	411.08	296.89							Fee Schedule		338							Fee Schedule																													411.08							Fee Schedule																																															
ETHICON RIGHT ANGLE BRK10	272	RC						Both			224.7	101.12	101.12	202.23	146.06							Fee Schedule		166.28							Fee Schedule																													202.23							Fee Schedule																																															
ETHICON STAPLE RELOAD ESC-10	272	RC						Both			575.4	258.93	258.93	517.86	374.01							Fee Schedule		425.8							Fee Schedule																													517.86							Fee Schedule																																															
ETHICON STAPLER # TLH90 *DISC.*	272	RC						Both			290.85	130.88	130.88	261.77	189.05							Fee Schedule		215.23							Fee Schedule																													261.77							Fee Schedule																																															
ETHICON STAPLER 25MM CURVED ECS25B	272	RC						Both			1097	493.65	493.65	987.3	713.05							Fee Schedule		811.78							Fee Schedule																													987.3							Fee Schedule																																															
ETHICON STAPLER TLC10  J&J	272	RC						Both			742	333.9	333.9	667.8	482.3							Fee Schedule		549.08							Fee Schedule																													667.8							Fee Schedule																																															
ETHICON STAPLER TLC55	272	RC						Both			352	158.4	158.4	316.8	228.8							Fee Schedule		260.48							Fee Schedule																													316.8							Fee Schedule																																															
ETHICON STONE RETRIEVER EPS 12	272	RC						Both			309.75	139.39	139.39	278.78	201.34							Fee Schedule		229.22							Fee Schedule																													278.78							Fee Schedule																																															
ETHICON SURGICAL STENT #M-649  (SENECA)	272	RC						Both			51.45	23.15	23.15	46.31	33.44							Fee Schedule		38.07							Fee Schedule																													46.31							Fee Schedule																																															
ETHICON SUTURE ASSIST DEVICE SW100	272	RC						Both			595.35	267.91	267.91	535.82	386.98							Fee Schedule		440.56							Fee Schedule																													535.82							Fee Schedule																																															
ETHICON TCR 75 RELOADS	272	RC						Both			269	121.05	121.05	242.1	174.85							Fee Schedule		199.06							Fee Schedule																													242.1							Fee Schedule																																															
ETHICON TL 90 LINEAR STAPLER	272	RC						Both			388.5	174.83	174.83	349.65	252.53							Fee Schedule		287.49							Fee Schedule																													349.65							Fee Schedule																																															
ETHICON TLC 55	272	RC						Both			393.75	177.19	177.19	354.38	255.94							Fee Schedule		291.38							Fee Schedule																													354.38							Fee Schedule																																															
ETHICON TLC 75	272	RC						Both			579.6	260.82	260.82	521.64	376.74							Fee Schedule		428.9							Fee Schedule																													521.64							Fee Schedule																																															
ETHICON TR35W RELOADS	270	RC						Both			308.7	138.92	138.92	277.83	200.66							Fee Schedule		228.44							Fee Schedule																													277.83							Fee Schedule																																															
ETHICON TR60 RELOAD	272	RC						Both			185.85	83.63	83.63	167.27	120.8							Fee Schedule		137.53							Fee Schedule																													167.27							Fee Schedule																																															
ETHICON TROCAR 512HN	272	RC						Both			224.7	101.12	101.12	202.23	146.06							Fee Schedule		166.28							Fee Schedule																													202.23							Fee Schedule																																															
ETHICON TROCAR D12LT	272	RC						Both			353.85	159.23	159.23	318.47	230							Fee Schedule		261.85							Fee Schedule																													318.47							Fee Schedule																																															
ETHICON TROCAR SLEEVE 2CB12LT	272	RC						Both			84	37.8	37.8	75.6	54.6							Fee Schedule		62.16							Fee Schedule																													75.6							Fee Schedule																																															
ETHICON TROCAR SLEEVE 2CB5LT	272	RC						Both			78.75	35.44	35.44	70.88	51.19							Fee Schedule		58.28							Fee Schedule																													70.88							Fee Schedule																																															
ETHICON TX30B  J&J	272	RC						Both			339.15	152.62	152.62	305.24	220.45							Fee Schedule		250.97							Fee Schedule																													305.24							Fee Schedule																																															
ETHICON WHITE RELOAD (ECR45W) GST45W  J&	272	RC						Both			727	327.15	327.15	654.3	472.55							Fee Schedule		537.98							Fee Schedule																													654.3							Fee Schedule																																															
ETHILON 0  L886T	272	RC						Both			14.7	6.62	6.62	13.23	9.56							Fee Schedule		10.88							Fee Schedule																													13.23							Fee Schedule																																															
ETHILON 0 L885T	272	RC						Both			8.4	3.78	3.78	7.56	5.46							Fee Schedule		6.22							Fee Schedule																													7.56							Fee Schedule																																															
ETHILON 2 825G	272	RC						Both			23.1	10.4	10.4	20.79	15.02							Fee Schedule		17.09							Fee Schedule																													20.79							Fee Schedule																																															
ETHILON 2.0 490T	272	RC						Both			14	6.3	6.3	12.6	9.1							Fee Schedule		10.36							Fee Schedule																													12.6							Fee Schedule																																															
ETHILON 2.0 664G	272	RC						Both			6	2.7	2.7	5.4	3.9							Fee Schedule		4.44							Fee Schedule																													5.4							Fee Schedule																																															
ETHILON 2.0 STEEL #M682G	272	RC						Both			38.85	17.48	17.48	34.97	25.25							Fee Schedule		28.75							Fee Schedule																													34.97							Fee Schedule																																															
ETHILON 2-0 1674BH	272	RC						Both			7	3.15	3.15	6.3	4.55							Fee Schedule		5.18							Fee Schedule																													6.3							Fee Schedule																																															
ETHILON 2-0 664G	272	RC						Both			4.2	1.89	1.89	3.78	2.73							Fee Schedule		3.11							Fee Schedule																													3.78							Fee Schedule																																															
ETHILON 2-0 664H	272	RC						Both			7	3.15	3.15	6.3	4.55							Fee Schedule		5.18							Fee Schedule																													6.3							Fee Schedule																																															
ETHILON 2-0 685G	272	RC						Both			6	2.7	2.7	5.4	3.9							Fee Schedule		4.44							Fee Schedule																													5.4							Fee Schedule																																															
ETHILON 2-O 664G	272	RC						Both			8.4	3.78	3.78	7.56	5.46							Fee Schedule		6.22							Fee Schedule																													7.56							Fee Schedule																																															
ETHILON 3.0 669H	272	RC						Both			7	3.15	3.15	6.3	4.55							Fee Schedule		5.18							Fee Schedule																													6.3							Fee Schedule																																															
ETHILON 3-0 1669H   J&J	272	RC						Both			14	6.3	6.3	12.6	9.1							Fee Schedule		10.36							Fee Schedule																													12.6							Fee Schedule																																															
ETHILON 3-0 1893G	272	RC						Both			14.7	6.62	6.62	13.23	9.56							Fee Schedule		10.88							Fee Schedule																													13.23							Fee Schedule																																															
ETHILON 3-0 663G	272	RC						Both			7	3.15	3.15	6.3	4.55							Fee Schedule		5.18							Fee Schedule																													6.3							Fee Schedule																																															
ETHILON 3-0 663G (WAS 663H)	272	RC						Both			7	3.15	3.15	6.3	4.55							Fee Schedule		5.18							Fee Schedule																													6.3							Fee Schedule																																															
ETHILON 4.0 1864G	272	RC						Both			17.85	8.03	8.03	16.07	11.6							Fee Schedule		13.21							Fee Schedule																													16.07							Fee Schedule																																															
ETHILON 4-0 #1629H	272	RC						Both			8	3.6	3.6	7.2	5.2							Fee Schedule		5.92							Fee Schedule																													7.2							Fee Schedule																																															
ETHILON 4-0 1667ZH (OLD# 1667H)	272	RC						Both			13.65	6.14	6.14	12.29	8.87							Fee Schedule		10.1							Fee Schedule																													12.29							Fee Schedule																																															
ETHILON 4-0 662G FS-2 NEEDLE	272	RC						Both			7	3.15	3.15	6.3	4.55							Fee Schedule		5.18							Fee Schedule																													6.3							Fee Schedule																																															
ETHILON 4-0 662H	272	RC						Both			7	3.15	3.15	6.3	4.55							Fee Schedule		5.18							Fee Schedule																													6.3							Fee Schedule																																															
ETHILON 4-0 662N	272	RC						Both			7.35	3.31	3.31	6.62	4.78							Fee Schedule		5.44							Fee Schedule																													6.62							Fee Schedule																																															
ETHILON 4-0 699G	272	RC						Both			14	6.3	6.3	12.6	9.1							Fee Schedule		10.36							Fee Schedule																													12.6							Fee Schedule																																															
ETHILON 4-0 699H	272	RC						Both			16	7.2	7.2	14.4	10.4							Fee Schedule		11.84							Fee Schedule																													14.4							Fee Schedule																																															
ETHILON 4-0 BUTTON #540G	272	RC						Both			35.7	16.07	16.07	32.13	23.21							Fee Schedule		26.42							Fee Schedule																													32.13							Fee Schedule																																															
ETHILON 4-0 PDS 2 Z504G	272	RC						Both			17.85	8.03	8.03	16.07	11.6							Fee Schedule		13.21							Fee Schedule																													16.07							Fee Schedule																																															
ETHILON 490T 5.0	272	RC						Both			14	6.3	6.3	12.6	9.1							Fee Schedule		10.36							Fee Schedule																													12.6							Fee Schedule																																															
ETHILON 5 0 1855G	272	RC						Both			10.5	4.73	4.73	9.45	6.83							Fee Schedule		7.77							Fee Schedule																													9.45							Fee Schedule																																															
ETHILON 5 0 668G	272	RC						Both			9.45	4.25	4.25	8.51	6.14							Fee Schedule		6.99							Fee Schedule																													8.51							Fee Schedule																																															
ETHILON 5 MB46G	272	RC						Both			74	33.3	33.3	66.6	48.1							Fee Schedule		54.76							Fee Schedule																													66.6							Fee Schedule																																															
ETHILON 5-0 1666G	272	RC						Both			1500	675	675	1350	975							Fee Schedule		1110							Fee Schedule																													1350							Fee Schedule																																															
ETHILON 5-0 1666H	272	RC						Both			13	5.85	5.85	11.7	8.45							Fee Schedule		9.62							Fee Schedule																													11.7							Fee Schedule																																															
ETHILON 5-0 166H	272	RC						Both			12.6	5.67	5.67	11.34	8.19							Fee Schedule		9.32							Fee Schedule																													11.34							Fee Schedule																																															
ETHILON 5-0 1865G PC3 NEEDLE	272	RC						Both			11.03	4.96	4.96	9.93	7.17							Fee Schedule		8.16							Fee Schedule																													9.93							Fee Schedule																																															
ETHILON 5-0 1955G	272	RC						Both			14.7	6.62	6.62	13.23	9.56							Fee Schedule		10.88							Fee Schedule																													13.23							Fee Schedule																																															
ETHILON 5-0 661G	272	RC						Both			7	3.15	3.15	6.3	4.55							Fee Schedule		5.18							Fee Schedule																													6.3							Fee Schedule																																															
ETHILON 5-0 661H	272	RC						Both			8	3.6	3.6	7.2	5.2							Fee Schedule		5.92							Fee Schedule																													7.2							Fee Schedule																																															
ETHILON 5-0 698G  (P3)  J&J	272	RC						Both			14	6.3	6.3	12.6	9.1							Fee Schedule		10.36							Fee Schedule																													12.6							Fee Schedule																																															
ETHILON 5-0 PDS 2 Z503G	272	RC						Both			17.85	8.03	8.03	16.07	11.6							Fee Schedule		13.21							Fee Schedule																													16.07							Fee Schedule																																															
ETHILON 6.0 660G REPLACE# 1665G	272	RC						Both			11.55	5.2	5.2	10.4	7.51							Fee Schedule		8.55							Fee Schedule																													10.4							Fee Schedule																																															
ETHILON 6.0 689G	272	RC						Both			9.45	4.25	4.25	8.51	6.14							Fee Schedule		6.99							Fee Schedule																													8.51							Fee Schedule																																															
ETHILON 6.0 697G	272	RC						Both			8.4	3.78	3.78	7.56	5.46							Fee Schedule		6.22							Fee Schedule																													7.56							Fee Schedule																																															
ETHILON 6.0 9706H HEMASEAL	272	RC						Both			53.55	24.1	24.1	48.2	34.81							Fee Schedule		39.63							Fee Schedule																													48.2							Fee Schedule																																															
ETHILON 6-0 1698G	272	RC						Both			12	5.4	5.4	10.8	7.8							Fee Schedule		8.88							Fee Schedule																													10.8							Fee Schedule																																															
ETHILON 6-0 1866G	272	RC						Both			15	6.75	6.75	13.5	9.75							Fee Schedule		11.1							Fee Schedule																													13.5							Fee Schedule																																															
ETHILON 9-0 12'DOUBLE NEEDLE 7760G	272	RC						Both			53	23.85	23.85	47.7	34.45							Fee Schedule		39.22							Fee Schedule																													47.7							Fee Schedule																																															
ETHILON ER CHARGE	270	RC						Both			17.85	8.03	8.03	16.07	11.6							Fee Schedule		13.21							Fee Schedule																													16.07							Fee Schedule																																															
ETHILON PDS 2 Z340	272	RC						Both			8.4	3.78	3.78	7.56	5.46							Fee Schedule		6.22							Fee Schedule																													7.56							Fee Schedule																																															
ETHILON PDS 2 Z970	272	RC						Both			4.2	1.89	1.89	3.78	2.73							Fee Schedule		3.11							Fee Schedule																													3.78							Fee Schedule																																															
ETHILON PDS 3-0 Z416H	272	RC						Both			9	4.05	4.05	8.1	5.85							Fee Schedule		6.66							Fee Schedule																													8.1							Fee Schedule																																															
ETHILON SILK SA63H	272	RC						Both			7.35	3.31	3.31	6.62	4.78							Fee Schedule		5.44							Fee Schedule																													6.62							Fee Schedule																																															
ETHILON STEEL SUTURE #M649G	272	RC						Both			34.65	15.59	15.59	31.19	22.52							Fee Schedule		25.64							Fee Schedule																													31.19							Fee Schedule																																															
ETHILON SURGICAL STEEL 539G	272	RC						Both			42	18.9	18.9	37.8	27.3							Fee Schedule		31.08							Fee Schedule																													37.8							Fee Schedule																																															
ETHMOZINE 200 MG TAB.(MORICIZINE)	250	RC	A9270	CPT				Both			4.2	1.89	0.01	3.78	0.01							Fee Schedule		3.11							Fee Schedule																													3.78							Fee Schedule																																															
ETHOSUXIMIDE 214 SERUM	301	RC	80168	CPT				Both			52.5	23.63	14.52	47.25	14.52							Fee Schedule		18.15							Fee Schedule		16.83							Fee Schedule		16.34							Fee Schedule											47.25							Fee Schedule																				16.34							Fee Schedule																				
ETHYLENE GLYCOL 801 2ML SERUM	301	RC	82693	CPT				Both			175.35	78.91	13.25	157.82	13.25							Fee Schedule		16.56							Fee Schedule		15.35							Fee Schedule		14.9							Fee Schedule		16.34							Fee Schedule		157.82							Fee Schedule		18.79							Fee Schedule		15.2							Fee Schedule		14.9							Fee Schedule		18.79							Fee Schedule		15.2							Fee Schedule		
ETILOCK	271	RC						Both			17.85	8.03	8.03	17.14	11.6							Fee Schedule		13.21							Fee Schedule																				14.9							Fee Schedule		16.07							Fee Schedule		17.14							Fee Schedule		13.86							Fee Schedule											17.14							Fee Schedule		13.86							Fee Schedule		
ETODOLAC 400MG (LODINE) TABLET	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
ETOMIDATE 2 MG/ML-10ML VIAL	250	RC	A9270	CPT				Both			29.4	13.23	0.01	26.46	0.01							Fee Schedule		21.76							Fee Schedule																													26.46							Fee Schedule																																															
ETT 2.5MM CUFFED #112480025	272	RC	A7521	CPT				Both			6.3	2.84	2.84	69.05	42.35							Fee Schedule		4.66							Fee Schedule		69.05							Fee Schedule		40.99							Fee Schedule											5.67							Fee Schedule																																															
ETT 3.0MM CUFFED  792-1-7333-30	272	RC	A7521	CPT				Both			6	2.7	2.7	77.1	42.35							Fee Schedule		4.44							Fee Schedule		69.05							Fee Schedule		40.99							Fee Schedule		67.04							Fee Schedule		5.4							Fee Schedule		77.1							Fee Schedule		62.35							Fee Schedule											77.1							Fee Schedule		62.35							Fee Schedule		
ETT 3.0MM CUFFED  792-1-7333-30	272	RC	A7521	CPT				Both			7	3.15	3.15	77.1	42.35							Fee Schedule		5.18							Fee Schedule		69.05							Fee Schedule		40.99							Fee Schedule		67.04							Fee Schedule		6.3							Fee Schedule		77.1							Fee Schedule		62.35							Fee Schedule											77.1							Fee Schedule		62.35							Fee Schedule		
ETT 4.0MM CUFFED 792-1-7333-40	272	RC	A7521	CPT				Both			7	3.15	3.15	77.1	42.35							Fee Schedule		5.18							Fee Schedule		69.05							Fee Schedule		40.99							Fee Schedule		67.04							Fee Schedule		6.3							Fee Schedule		77.1							Fee Schedule		62.35							Fee Schedule											77.1							Fee Schedule		62.35							Fee Schedule		
ETT 5.0MM CUFFED #86446	272	RC	A7521	CPT				Both			8	3.6	3.6	77.1	42.35							Fee Schedule		5.92							Fee Schedule		69.05							Fee Schedule		40.99							Fee Schedule		67.04							Fee Schedule		7.2							Fee Schedule		77.1							Fee Schedule		62.35							Fee Schedule											77.1							Fee Schedule		62.35							Fee Schedule		
EUCERIN CREAM 4 OZ	250	RC	A9270	CPT				Both			20.38	9.17	0.01	77.1	0.01							Fee Schedule		15.08							Fee Schedule																				67.04							Fee Schedule		18.34							Fee Schedule		77.1							Fee Schedule		62.35							Fee Schedule											77.1							Fee Schedule		62.35							Fee Schedule		
EVACUATED CONTAINER #1A8504  #622299-NEW	258	RC						Both			43	19.35	19.35	38.7	27.95							Fee Schedule		31.82							Fee Schedule																													38.7							Fee Schedule																																															
EVAL NEEDLE ASPIR REPORT CYTOGY INTERP	311	RC	88173	CPT				Both			300	135	53.75	270	53.75							Fee Schedule		73.44							Fee Schedule											87.67							Fee Schedule											270							Fee Schedule																																															
EVAL NEEDLE ASPIR STUDY CYTOHISTO	311	RC	88172	CPT				Both			165.9	74.66	13.45	149.31	13.45							Fee Schedule		17.72							Fee Schedule											18.95							Fee Schedule											149.31							Fee Schedule																																															
EVARREST FIBRIN SEALANT PATCH #EVT5024	272	RC						Both			4095	1842.75	1842.75	3685.5	2661.75							Fee Schedule		3030.3							Fee Schedule																													3685.5							Fee Schedule																																															
EVENITY 210MG/2.34ML SYRINGE	636	RC	J3111	CPT				Both			7303.08	3286.39	12.19	6572.77		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	12.19							Fee Schedule		12.47							Fee Schedule																				6572.77							Fee Schedule																																															
EVOLVE PROLINE HEAD 24MM +2 496H224	278	RC	C1776	CPT				Both			9254.7	4164.62	11.26	8329.23		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	6848.48							Fee Schedule																				12.11							Fee Schedule		8329.23							Fee Schedule		13.93							Fee Schedule		11.26							Fee Schedule											13.93							Fee Schedule		11.26							Fee Schedule		
EVOLVE PROLINE HEAD 24MM 496H024	278	RC	C1776	CPT				Both			9254.7	4164.62	4164.62	8329.23		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	6848.48							Fee Schedule																													8329.23							Fee Schedule																																															
EVOLVE PROLINE STEM 8.5MM 496S085	278	RC	C1776	CPT				Both			10996.65	4948.49	4948.49	9896.99		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	8137.52							Fee Schedule																													9896.99							Fee Schedule																																															
EXACTO COLD SNARE # 00711115 ( STERIS )	272	RC						Both			78.75	35.44	35.44	70.88	51.19							Fee Schedule		58.28							Fee Schedule																													70.88							Fee Schedule																																															
EXCEDRIN TAB	250	RC	A9270	CPT				Both			5.25	2.36	0.01	4.73	0.01							Fee Schedule		3.89							Fee Schedule																													4.73							Fee Schedule																																															
EXCILON DRAIN SPONGE 4X4 #7086	272	RC						Both			12	5.4	5.4	10.8	7.8							Fee Schedule		8.88							Fee Schedule																													10.8							Fee Schedule																																															
EXELON 4.6 MG TRANSDERMAL PATCH	250	RC						Both			21.63	9.73	9.73	19.47	14.06							Fee Schedule		16.01							Fee Schedule																													19.47							Fee Schedule																																															
EX-LAX PILLS	250	RC	A9270	CPT				Both			5.04	2.27	0.01	4.54	0.01							Fee Schedule		3.73							Fee Schedule																													4.54							Fee Schedule																																															
EXPAREL 1.3% 20ML SDV	636	RC	J0666	CPT				Both			1226.4	551.88	1.41	1103.76		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1.41							Fee Schedule		1.48							Fee Schedule																				1103.76							Fee Schedule																																															
EXPRESS LD BILIARY STENT H74938046830750	278	RC	C1874	CPT				Both			3900	1755	1.34	3510		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	2886							Fee Schedule																				1.44							Fee Schedule		3510							Fee Schedule		1.65							Fee Schedule		1.34							Fee Schedule											1.65							Fee Schedule		1.34							Fee Schedule		
EXPRESS LD BILIARY STENT H74938046840750	278	RC	C1874	CPT				Both			3900	1755	1755	3510		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	2886							Fee Schedule																													3510							Fee Schedule																																															
EXT ASSIST SIZE A	270	RC						Both			56.7	25.52	25.52	51.03	36.86							Fee Schedule		41.96							Fee Schedule																													51.03							Fee Schedule																																															
EXT ASSIST SIZE B	270	RC						Both			56.7	25.52	25.52	51.03	36.86							Fee Schedule		41.96							Fee Schedule																													51.03							Fee Schedule																																															
EXT ASSIST SIZE C	270	RC						Both			56.7	25.52	25.52	51.03	36.86							Fee Schedule		41.96							Fee Schedule																													51.03							Fee Schedule																																															
EXTENSION SET 30  12656-28	272	RC						Both			3	1.35	1.35	2.7	1.95							Fee Schedule		2.22							Fee Schedule																													2.7							Fee Schedule																																															
EXTENSION SET 34 INCH 2C6227/ 2C5627	272	RC						Both			3	1.35	1.35	2.7	1.95							Fee Schedule		2.22							Fee Schedule																													2.7							Fee Schedule																																															
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITH CC"					327	DRG		Inpatient			144185.32	64883.39	64883.39	64883.39							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period	
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITHOUT CC/MCC"					328	DRG		Inpatient			34789.45	15655.25	15655.25	15655.25							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period	
EXTRACTOR PRO RETRIEVE BALLOON M00547100	272	RC	C1726	CPT				Both			310	139.5	135.94	279	135.94							Fee Schedule		229.4							Fee Schedule																													279							Fee Schedule																																															
EXTRACTOR PRO RX #M00547010	272	RC						Both			462	207.9	207.9	415.8	300.3							Fee Schedule		341.88							Fee Schedule																													415.8							Fee Schedule																																															
EXTRACTOR PRO XL #M00547110	272	RC						Both			310	139.5	139.5	279	201.5							Fee Schedule		229.4							Fee Schedule																													279							Fee Schedule																																															
EXTRACTOR PRO XL 11.5 3L RB #M00547140	272	RC						Both			310	139.5	139.5	279	201.5							Fee Schedule		229.4							Fee Schedule																													279							Fee Schedule																																															
EXTREMITY PACK UPPER #DYNJP8040S MEDLINE	270	RC						Both			42	18.9	18.9	37.8	27.3							Fee Schedule		31.08							Fee Schedule																													37.8							Fee Schedule																																															
EXTREMITY UPPER DRAPE MEDLINE #DYNJP8002	272	RC						Both			17	7.65	7.65	15.3	11.05							Fee Schedule		12.58							Fee Schedule																													15.3							Fee Schedule																																															
EXUDERM LP LOW-PROFILE 4X4  #MSC5100	272	RC	A6234	CPT				Both			5	2.25	2.25	9.61	5.89							Fee Schedule		3.7							Fee Schedule		9.61							Fee Schedule		7.36							Fee Schedule											4.5							Fee Schedule																																															
EYE MULTIVITAMIN TABLET	250	RC	A9270	CPT				Both			6.3	2.84	0.01	10.73	0.01							Fee Schedule		4.66							Fee Schedule																				9.33							Fee Schedule		5.67							Fee Schedule		10.73							Fee Schedule		8.68							Fee Schedule											10.73							Fee Schedule		8.68							Fee Schedule		
EYE PADS	271	RC						Both			1.05	0.47	0.47	0.95	0.68							Fee Schedule		0.78							Fee Schedule																													0.95							Fee Schedule																																															
EYE PADS #841	623	RC	A6410	CPT				Both			1	0.45	0.34	0.9	0.34							Fee Schedule		0.74							Fee Schedule		0.55							Fee Schedule																				0.9							Fee Schedule																																															
EYE WASH STERILE SOLUTION-120ML	250	RC	A9270	CPT				Both			12.98	5.84	0.01	11.68	0.01							Fee Schedule		9.61							Fee Schedule																				0.53							Fee Schedule		11.68							Fee Schedule		0.61							Fee Schedule		0.49							Fee Schedule											0.61							Fee Schedule		0.49							Fee Schedule		
EZ BRONCHIAL BLOCKER MG-02770-002	272	RC						Both			593.25	266.96	266.96	533.93	385.61							Fee Schedule		439.01							Fee Schedule																													533.93							Fee Schedule																																															
EZ PAP 23-0747 (301-6000) TRI-ANIM	271	RC						Both			69	31.05	31.05	62.1	44.85							Fee Schedule		51.06							Fee Schedule																													62.1							Fee Schedule																																															
EZ PAP PRESSURE GAUGE 301-5558 TRIANIM	271	RC						Both			27	12.15	12.15	24.3	17.55							Fee Schedule		19.98							Fee Schedule																													24.3							Fee Schedule																																															
EZ PAP W/1.25 XOPENEX	412	RC	94640	CPT				Both			283.5	127.58	12.53	286	175							Per Diem		209.79							Fee Schedule											12.53							Fee Schedule											255.15							Fee Schedule																				286							Case Rate																				
E-Z SCRUB BRUSHES (DISC.)	272	RC	A4248	CPT				Both			3.15	1.42	1.25	2.84	1.25							Fee Schedule		2.33							Fee Schedule																													2.84							Fee Schedule																																															
EZ WRAP #1016  (SENECA)	272	RC						Both			2	0.9	0.9	1.8	1.3							Fee Schedule		1.48							Fee Schedule																													1.8							Fee Schedule																																															
EZETIMIBE (ZETIA )10 MG  TABLET	250	RC	A9270	CPT				Both			9.45	4.25	0.01	8.51	0.01							Fee Schedule		6.99							Fee Schedule																													8.51							Fee Schedule																																															
FACE MASK FULL JASON STYLE (TRI-ANIM)	270	RC	A7030	CPT				Both			496.65	223.49	69.06	446.99	69.06							Fee Schedule		367.52							Fee Schedule		113.87							Fee Schedule																				446.99							Fee Schedule																																															
FACE SHIELD FULL #NONFS300 (MEDLINE)	270	RC						Both			4.1	1.85	1.85	127.13	2.67							Fee Schedule		3.03							Fee Schedule																				110.55							Fee Schedule		3.69							Fee Schedule		127.13							Fee Schedule		102.81							Fee Schedule											127.13							Fee Schedule		102.81							Fee Schedule		
FACE TENT HUDSON #1095 (SENECA)	271	RC						Both			7.35	3.31	3.31	6.62	4.78							Fee Schedule		5.44							Fee Schedule																													6.62							Fee Schedule																																															
FACE TENT SUPPLY	270	RC	A4619	CPT				Both			9.45	4.25	1.56	8.51	1.56							Fee Schedule		6.99							Fee Schedule		2.65							Fee Schedule																				8.51							Fee Schedule																																															
FACIAL BONES 2V	320	RC	70150	CPT				Both			315	141.75	2.39	318	22.88							Fee Schedule		27.47							Fee Schedule											22.35							Fee Schedule		2.57							Fee Schedule		283.5							Fee Schedule		2.96							Fee Schedule		2.39							Fee Schedule		318							Per Diem		2.96							Fee Schedule		2.39							Fee Schedule		
FALLOP RING GUIDE 000875-901	270	RC						Both			233.1	104.9	104.9	209.79	151.52							Fee Schedule		172.49							Fee Schedule																													209.79							Fee Schedule																																															
FALLOP RINGS (ACMI CIRCON)	270	RC						Both			263.55	118.6	118.6	237.2	171.31							Fee Schedule		195.03							Fee Schedule																													237.2							Fee Schedule																																															
FALOPE RING BAND APPLIC KIT # 005280-901	272	RC						Both			917.7	412.97	412.97	825.93	596.51							Fee Schedule		679.1							Fee Schedule																													825.93							Fee Schedule																																															
FAMOTIDINE 20 MG/2 ML (PEPCID) VIAL	250	RC	J1308	CPT				Both			12.6	5.67	0.01	11.34	8.19							Fee Schedule		9.32							Fee Schedule		0.01							Fee Schedule																				11.34							Fee Schedule																																															
FAMOTIDINE 20 MG/50ML PREMIX IVPB	250	RC	J1308	CPT				Both			36.75	16.54	0.01	33.08	23.89							Fee Schedule		27.2							Fee Schedule		0.01							Fee Schedule											0.01							Fee Schedule		33.08							Fee Schedule		0.01							Fee Schedule		0.01							Fee Schedule											0.01							Fee Schedule		0.01							Fee Schedule		
FAMOTIDINE 20MG (PEPCID) TABLET	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																				0.01							Fee Schedule		5.67							Fee Schedule		0.01							Fee Schedule		0.01							Fee Schedule											0.01							Fee Schedule		0.01							Fee Schedule		
FAMOTIDINE ORAL SUSPENSION 40MG/5ML-50ML	250	RC	A9270	CPT				Both			371.7	167.27	0.01	334.53	0.01							Fee Schedule		275.06							Fee Schedule																													334.53							Fee Schedule																																															
FASLODEX 250MG/5ML	636	RC	J9395	CPT				Both			3054.45	1374.5	5.44	2749.01		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	2260.29							Fee Schedule		5.44							Fee Schedule																				2749.01							Fee Schedule																																															
FAST FIX 360 CURVE KNOT PUSHER #72202675	272	RC						Both			318	143.1	4.91	286.2	206.7							Fee Schedule		235.32							Fee Schedule																				5.28							Fee Schedule		286.2							Fee Schedule		6.07							Fee Schedule		4.91							Fee Schedule											6.07							Fee Schedule		4.91							Fee Schedule		
FAT EMULSION IV 20% 500ML 2B6063	258	RC	B4185	CPT				Both			140.1	63.05	7.22	126.09	7.22							Fee Schedule		103.67							Fee Schedule																													126.09							Fee Schedule																																															
FATTY ACIDS 449 1ML EDTA	301	RC	82725	CPT				Both			74.55	33.55	13.51	67.1	13.51							Fee Schedule		18.77							Fee Schedule		19.33							Fee Schedule		18.77							Fee Schedule											67.1							Fee Schedule																				18.77							Fee Schedule																				
FECAL CALPROTECTIN 16796	301	RC	83993	CPT				Both			286.65	128.99	17.45	257.99	17.45							Fee Schedule		21.81							Fee Schedule		20.22							Fee Schedule		19.63							Fee Schedule		18.77							Fee Schedule		257.99							Fee Schedule		21.59							Fee Schedule		17.46							Fee Schedule		19.63							Fee Schedule		21.59							Fee Schedule		17.46							Fee Schedule		
FECAL COLLECTION BAG ONLY  SMS2B1L	270	RC	A4335	CPT				Both			16	7.2	7.2	22.57	10.4							Fee Schedule		11.84							Fee Schedule																				19.63							Fee Schedule		14.4							Fee Schedule		22.57							Fee Schedule		18.26							Fee Schedule											22.57							Fee Schedule		18.26							Fee Schedule		
FECAL COLLECTION KIT #SMS002 ( SENECA )	270	RC	A4337	CPT				Both			794	357.3	357.3	714.6	516.1							Fee Schedule		587.56							Fee Schedule																													714.6							Fee Schedule																																															
FECAL FAT 72 HR QUANT 455	301	RC	82710	CPT				Both			175.35	78.91	14.94	157.82	14.94							Fee Schedule		18.67							Fee Schedule		17.3							Fee Schedule		16.8							Fee Schedule											157.82							Fee Schedule																				16.8							Fee Schedule																				
FECAL FAT QUAL SUDAN STAIN STOOL FZ 3967	301	RC	82705	CPT				Both			37.8	17.01	4.53	34.02	4.53							Fee Schedule		5.66							Fee Schedule		5.25							Fee Schedule		5.1							Fee Schedule		16.8							Fee Schedule		34.02							Fee Schedule		19.32							Fee Schedule		15.62							Fee Schedule		5.1							Fee Schedule		19.32							Fee Schedule		15.62							Fee Schedule		
FECAL FAT QUALITATIVE 3967	301	RC	82705	CPT				Both			42	18.9	4.53	37.8	4.53							Fee Schedule		5.66							Fee Schedule		5.25							Fee Schedule		5.1							Fee Schedule		5.1							Fee Schedule		37.8							Fee Schedule		5.87							Fee Schedule		4.74							Fee Schedule		5.1							Fee Schedule		5.87							Fee Schedule		4.74							Fee Schedule		
FEEDING BAG	271	RC						Both			17.85	8.03	4.74	16.07	11.6							Fee Schedule		13.21							Fee Schedule																				5.1							Fee Schedule		16.07							Fee Schedule		5.87							Fee Schedule		4.74							Fee Schedule											5.87							Fee Schedule		4.74							Fee Schedule		
FEEDING TUBE 5 FR INFANT 461412E	271	RC						Both			5.25	2.36	2.36	4.73	3.41							Fee Schedule		3.89							Fee Schedule																													4.73							Fee Schedule																																															
FEEDING TUBE 5 FR. (ARGYLE) 460802E	271	RC						Both			5	2.25	2.25	4.5	3.25							Fee Schedule		3.7							Fee Schedule																													4.5							Fee Schedule																																															
FEEDING TUBE 8FR  ARGYLE 460406	271	RC						Both			3	1.35	1.35	2.7	1.95							Fee Schedule		2.22							Fee Schedule																													2.7							Fee Schedule																																															
FEEDING TUBE DECLOGGER BIONIX #922	272	RC	B9998	CPT				Both			21	9.45	9.45	18.9	13.65							Fee Schedule		15.54							Fee Schedule																													18.9							Fee Schedule																																															
FEEDING TUBE NCJ KIT VIVONEX (SENECA)	272	RC						Both			236.25	106.31	106.31	212.63	153.56							Fee Schedule		174.83							Fee Schedule																													212.63							Fee Schedule																																															
FELBATOL 3081 SERUM 2ML REFRIG	301	RC	80299	CPT				Both			106.05	47.72	13.42	95.45	13.42							Fee Schedule		18.64							Fee Schedule		19.2							Fee Schedule		18.64							Fee Schedule											95.45							Fee Schedule																				18.64							Fee Schedule																				
FELODIPINE ER 5MG (PLENDIL) TABLET	250	RC	A9270	CPT				Both			6.3	2.84	0.01	21.44	0.01							Fee Schedule		4.66							Fee Schedule																				18.64							Fee Schedule		5.67							Fee Schedule		21.44							Fee Schedule		17.34							Fee Schedule											21.44							Fee Schedule		17.34							Fee Schedule		
FEM CAM BRUSH WT SUCT	272	RC						Both			55.65	25.04	25.04	50.09	36.17							Fee Schedule		41.18							Fee Schedule																													50.09							Fee Schedule																																															
FEMARA 2.5 MG (LETROZOLE) TABLET UD	250	RC	A9270	CPT				Both			25.2	11.34	0.01	22.68	0.01							Fee Schedule		18.65							Fee Schedule																													22.68							Fee Schedule																																															
FEMORAL ARTERIAL LINE SAFE ASK-04018-UPM	272	RC						Both			133.5	60.08	60.08	120.15	86.78							Fee Schedule		98.79							Fee Schedule																													120.15							Fee Schedule																																															
FEMOSTOP FEMORAL COMP. SYSTEM  C11165	272	RC						Both			367.5	165.38	165.38	330.75	238.88							Fee Schedule		271.95							Fee Schedule																													330.75							Fee Schedule																																															
FEMSTAT 3	250	RC	A9270	CPT				Both			45.45	20.45	0.01	40.91	0.01							Fee Schedule		33.63							Fee Schedule																													40.91							Fee Schedule																																															
FEMSTAT PREFILL	250	RC	A9270	CPT				Both			55.41	24.93	0.01	49.87	0.01							Fee Schedule		41							Fee Schedule																													49.87							Fee Schedule																																															
FEMUR LT	320	RC	73552	CPT				Both			315	141.75	16.61	318	19.09							Fee Schedule		21.95							Fee Schedule											16.61							Fee Schedule											283.5							Fee Schedule																				318							Per Diem																				
FEMUR RT	320	RC	73552	CPT				Both			315	141.75	16.61	318	19.09							Fee Schedule		21.95							Fee Schedule											16.61							Fee Schedule											283.5							Fee Schedule																				318							Per Diem																				
FENOFIBRATE 160 MG TABLET UD	250	RC	A9270	CPT				Both			8.13	3.66	0.01	7.32	0.01							Fee Schedule		6.02							Fee Schedule																													7.32							Fee Schedule																																															
FENOFIBRATE 54 MG TABLET UD	250	RC	A9270	CPT				Both			4.2	1.89	0.01	3.78	0.01							Fee Schedule		3.11							Fee Schedule																													3.78							Fee Schedule																																															
FENOFIBRIC ACID 135 MG	250	RC	A9270	CPT				Both			18.9	8.51	0.01	17.01	0.01							Fee Schedule		13.99							Fee Schedule																													17.01							Fee Schedule																																															
FENOFIBRIC ACID 45 MG	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
FENT 2MCG/ML/ROPIVA 0.2%-100ML PREMIX	250	RC	J3010	CPT				Both			92.28	41.53	0.99	83.05	0.99							Fee Schedule		68.29							Fee Schedule		1.43							Fee Schedule		3.77							Fee Schedule											83.05							Fee Schedule																																															
FENT 2MCG/ML/ROPIVA 0.2%-200ML PREMIX	250	RC	J3010	CPT				Both			246.24	110.81	0.99	221.62	0.99							Fee Schedule		182.22							Fee Schedule		1.43							Fee Schedule		3.77							Fee Schedule		1.39							Fee Schedule		221.62							Fee Schedule		1.59							Fee Schedule		1.29							Fee Schedule											1.59							Fee Schedule		1.29							Fee Schedule		
FENT 2MCG/ML/ROPIVACAINE 0.2%-100ML IVPB	250	RC	J3010	CPT				Both			298.2	134.19	0.99	268.38	0.99							Fee Schedule		220.67							Fee Schedule		1.43							Fee Schedule		3.77							Fee Schedule		1.39							Fee Schedule		268.38							Fee Schedule		1.59							Fee Schedule		1.29							Fee Schedule											1.59							Fee Schedule		1.29							Fee Schedule		
FENTANY 2MCG/ML/ROPIVACAINE 0.2%-200ML	250	RC						Both			286.35	128.86	1.29	257.72	186.13							Fee Schedule		211.9							Fee Schedule																				1.39							Fee Schedule		257.72							Fee Schedule		1.59							Fee Schedule		1.29							Fee Schedule											1.59							Fee Schedule		1.29							Fee Schedule		
FENTANYL	301	RC	80307	CPT				Both			100.2	45.09	45.09	90.18	51.72							Fee Schedule		64.65							Fee Schedule		64							Fee Schedule		62.14							Fee Schedule											90.18							Fee Schedule																				62.14							Fee Schedule																				
FENTANYL  12.5 MCG TRANSDERMAL PATCH	250	RC	A9270	CPT				Both			47.25	21.26	0.01	71.46	0.01							Fee Schedule		34.97							Fee Schedule																				62.14							Fee Schedule		42.53							Fee Schedule		71.46							Fee Schedule		57.79							Fee Schedule											71.46							Fee Schedule		57.79							Fee Schedule		
FENTANYL  25 MCG TRANSDERMAL PATCH	250	RC	A9270	CPT				Both			56.7	25.52	0.01	51.03	0.01							Fee Schedule		41.96							Fee Schedule																													51.03							Fee Schedule																																															
FENTANYL  50 MCG TRANSDERMAL PATCH	250	RC	A9270	CPT				Both			103.95	46.78	0.01	93.56	0.01							Fee Schedule		76.92							Fee Schedule																													93.56							Fee Schedule																																															
FENTANYL  75 MCG TRANSDERMAL PATCH	250	RC	A9270	CPT				Both			157.5	70.88	0.01	141.75	0.01							Fee Schedule		116.55							Fee Schedule																													141.75							Fee Schedule																																															
FENTANYL 100 MCG TRANSDERAMAL PATCH	250	RC	A9270	CPT				Both			93.45	42.05	0.01	84.11	0.01							Fee Schedule		69.15							Fee Schedule																													84.11							Fee Schedule																																															
FENTANYL 100 MCG/2 ML INJ	636	RC	J3010	CPT				Both			12.6	5.67	1.43	11.34		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	9.32							Fee Schedule		1.43							Fee Schedule		3.77							Fee Schedule											11.34							Fee Schedule																																															
FENTANYL 250 MCG/5 ML INJ	636	RC	J3010	CPT				Both			12.6	5.67	1.29	11.34		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	9.32							Fee Schedule		1.43							Fee Schedule		3.77							Fee Schedule		1.39							Fee Schedule		11.34							Fee Schedule		1.59							Fee Schedule		1.29							Fee Schedule											1.59							Fee Schedule		1.29							Fee Schedule		
FENTANYL 2500MCG/NS 250ML PREMIX (QUVA)	636	RC	J7999	CPT				Both			77.55	34.9	1.29	69.8		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	57.39							Fee Schedule																				1.39							Fee Schedule		69.8							Fee Schedule		1.59							Fee Schedule		1.29							Fee Schedule											1.59							Fee Schedule		1.29							Fee Schedule		
FENTANYL 2MCG/ML/BUPIVACINE 0.125% IVPB	636	RC						Both			48.04	21.62	21.62	43.24		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	35.55							Fee Schedule																													43.24							Fee Schedule																																															
FENTANYL 50MCG/ML-50ML PCA	636	RC	J3010	CPT				Both			106.05	47.72	1.43	95.45		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	78.48							Fee Schedule		1.43							Fee Schedule		3.77							Fee Schedule											95.45							Fee Schedule																																															
FENTANYL AMPULE (PER ML) 100 MCG/2ML	636	RC	J3010	CPT				Both			10.5	4.73	1.29	9.45		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	7.77							Fee Schedule		1.43							Fee Schedule		3.77							Fee Schedule		1.39							Fee Schedule		9.45							Fee Schedule		1.59							Fee Schedule		1.29							Fee Schedule											1.59							Fee Schedule		1.29							Fee Schedule		
FENTANYL EPIDURAL	636	RC	J3010	CPT				Both			118.23	53.2	1.29	106.41		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	87.49							Fee Schedule		1.43							Fee Schedule		3.77							Fee Schedule		1.39							Fee Schedule		106.41							Fee Schedule		1.59							Fee Schedule		1.29							Fee Schedule											1.59							Fee Schedule		1.29							Fee Schedule		
FENTANYL STANDARD DRIP 2500MCG/NS 250ML	636	RC	J3010	CPT				Both			121.8	54.81	1.29	109.62		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	90.13							Fee Schedule		1.43							Fee Schedule		3.77							Fee Schedule		1.39							Fee Schedule		109.62							Fee Schedule		1.59							Fee Schedule		1.29							Fee Schedule											1.59							Fee Schedule		1.29							Fee Schedule		
FERN TEST AMNIOTIC FLUID	306	RC	89060	CPT				Both			44.1	19.85	1.29	39.69	6.36							Fee Schedule		7.95							Fee Schedule		7.55							Fee Schedule		7.33							Fee Schedule		1.39							Fee Schedule		39.69							Fee Schedule		1.59							Fee Schedule		1.29							Fee Schedule		7.33							Fee Schedule		1.59							Fee Schedule		1.29							Fee Schedule		
FERRITIN	301	RC	82728	CPT				Both			97.65	43.94	6.82	87.89	12.12							Fee Schedule		15.15							Fee Schedule		14.04							Fee Schedule		13.63							Fee Schedule		7.33							Fee Schedule		87.89							Fee Schedule		8.43							Fee Schedule		6.82							Fee Schedule		13.63							Fee Schedule		8.43							Fee Schedule		6.82							Fee Schedule		
FERRLECIT 125MG/NS 100ML IVPB	636	RC	J2916	CPT				Both			65.1	29.3	2.26	58.59		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	48.17							Fee Schedule		2.26							Fee Schedule											13.63							Fee Schedule		58.59							Fee Schedule		15.67							Fee Schedule		12.68							Fee Schedule											15.67							Fee Schedule		12.68							Fee Schedule		
FERRLECIT 62.5MG/5ML INJECTION	636	RC	J2916	CPT				Both			114.38	51.47	2.04	102.94		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	84.64							Fee Schedule		2.26							Fee Schedule											2.2							Fee Schedule		102.94							Fee Schedule		2.53							Fee Schedule		2.04							Fee Schedule											2.53							Fee Schedule		2.04							Fee Schedule		
FERRO-SEQUELS TABS	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																				2.2							Fee Schedule		5.67							Fee Schedule		2.53							Fee Schedule		2.04							Fee Schedule											2.53							Fee Schedule		2.04							Fee Schedule		
FERROUS SULFATE 220 MG/5ML ELIXIR UD	250	RC	A9270	CPT				Both			5.25	2.36	0.01	4.73	0.01							Fee Schedule		3.89							Fee Schedule																													4.73							Fee Schedule																																															
FERROUS SULFATE 300 MG/5ML LIQUID UD	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
FERROUS SULFATE 325MG TAB	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
FERROUS SULFATE DROPS	250	RC	A9270	CPT				Both			14.24	6.41	0.01	12.82	0.01							Fee Schedule		10.54							Fee Schedule																													12.82							Fee Schedule																																															
FETAL FIBRONECTIN	300	RC	82731	CPT				Both			389.55	175.3	57.25	350.6	57.25							Fee Schedule		71.57							Fee Schedule		66.34							Fee Schedule		64.41							Fee Schedule											350.6							Fee Schedule																				64.41							Fee Schedule																				
FETAL HEART MONITOR	732	RC	59050	CPT				Both			475.65	214.04	49.66	481	49.66							Fee Schedule		351.98							Fee Schedule																				64.41							Fee Schedule		428.09							Fee Schedule		74.07							Fee Schedule		59.9							Fee Schedule		481							Per Diem		74.07							Fee Schedule		59.9							Fee Schedule		
FETAL MONITOR	483	RC	76825	CPT				Both			661.5	297.68	55.69	668	420							Per Diem		175.4							Fee Schedule											55.69							Fee Schedule											595.35							Fee Schedule																				668							Per Diem																				
FETAL PILLOW #FP-010	272	RC						Both			3228	1452.6	1452.6	2905.2	2098.2							Fee Schedule		2388.72							Fee Schedule																													2905.2							Fee Schedule																																															
FETAL SCALP ELECTRODE 7000AAO	271	RC						Both			13	5.85	5.85	11.7	8.45							Fee Schedule		9.62							Fee Schedule																													11.7							Fee Schedule																																															
FETAL SCALP ELECTRODE ATTACH 2464AAO	271	RC						Both			4	1.8	1.8	3.6	2.6							Fee Schedule		2.96							Fee Schedule																													3.6							Fee Schedule																																															
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC					329	DRG		Inpatient			106118.44	47753.3	47753.3	47753.3							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period. 				37430.83	37430.83	37430.83	1 through 10									0		No services provided during 15 month lookback period				27440.06	27440.06	27440.06	1 through 10									0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period	
FEXOFENADINE 180MG ER TABLET UD	250	RC	A9270	CPT				Both			9.45	4.25	0.01	8.51	0.01							Fee Schedule		6.99							Fee Schedule																													8.51							Fee Schedule																																															
FEXOFENADINE 60MG TABLET UD	250	RC	A9270	CPT				Both			8.4	3.78	0.01	7.56	0.01							Fee Schedule		6.22							Fee Schedule																													7.56							Fee Schedule																																															
FIBERCON TABLETS	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
FIBRACOL COLLAGEN DSG. 4X4   #2982	270	RC						Both			14.7	6.62	6.62	13.23	9.56							Fee Schedule		10.88							Fee Schedule																													13.23							Fee Schedule																																															
FIBRIN SPLIT PRODUCTS  458	305	RC	85362	CPT				Both			57.75	25.99	6.13	51.98	6.13							Fee Schedule		7.65							Fee Schedule		7.1							Fee Schedule		6.89							Fee Schedule											51.98							Fee Schedule																				6.89							Fee Schedule																				
FIBRINOGEN	305	RC	85384	CPT				Both			54.6	24.57	6.41	49.14	7.55							Fee Schedule		9.72							Fee Schedule		10.01							Fee Schedule		9.72							Fee Schedule		6.89							Fee Schedule		49.14							Fee Schedule		7.92							Fee Schedule		6.41							Fee Schedule		9.72							Fee Schedule		7.92							Fee Schedule		6.41							Fee Schedule		
FIBRINOGEN DEGRA  458	305	RC	85370	CPT				Both			57.75	25.99	9.04	51.98	10.09							Fee Schedule		12.62							Fee Schedule		12.8							Fee Schedule		12.43							Fee Schedule		9.72							Fee Schedule		51.98							Fee Schedule		11.18							Fee Schedule		9.04							Fee Schedule		12.43							Fee Schedule		11.18							Fee Schedule		9.04							Fee Schedule		
FIDUCIAL MARKER BLOCK  4535-300-96541	278	RC	A4648	CPT				Both			441	198.45	11.56	396.9		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	326.34							Fee Schedule																				12.43							Fee Schedule		396.9							Fee Schedule		14.29							Fee Schedule		11.56							Fee Schedule											14.29							Fee Schedule		11.56							Fee Schedule		
FILM COPIES	320	RC						Both			34.65	15.59	15.59	318	22.52							Fee Schedule		25.64							Fee Schedule																													31.19							Fee Schedule																				318							Per Diem																				
FILSHIE CLIPS # AVM-851J  ( COOPER SURGI	278	RC	A4264	CPT				Both			354.9	159.71	159.71	319.41		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	262.63							Fee Schedule																													319.41							Fee Schedule																																															
FILTER  FOR VENT # D/X800  ( OLD VENT )	270	RC						Both			34	15.3	15.3	30.6	22.1							Fee Schedule		25.16							Fee Schedule																													30.6							Fee Schedule																																															
FILTER AEROSOL EXHALATION  8980	272	RC						Both			5.25	2.36	2.36	4.73	3.41							Fee Schedule		3.89							Fee Schedule																													4.73							Fee Schedule																																															
FILTER BACTERIA #87-FH603003 (TRI-ANIM)	270	RC						Both			9.45	4.25	4.25	8.51	6.14							Fee Schedule		6.99							Fee Schedule																													8.51							Fee Schedule																																															
FILTER D/FLEX 4-074601-00 ( OLD VENT )	270	RC						Both			14	6.3	6.3	12.6	9.1							Fee Schedule		10.36							Fee Schedule																													12.6							Fee Schedule																																															
FILTER LARGE BACTERIA #4-010793-00 (NELL	270	RC						Both			28.35	12.76	12.76	25.52	18.43							Fee Schedule		20.98							Fee Schedule																													25.52							Fee Schedule																																															
FILTER STRAW 1 3/4  NURSERY  #415021	272	RC						Both			2.1	0.95	0.95	1.89	1.37							Fee Schedule		1.55							Fee Schedule																													1.89							Fee Schedule																																															
FILTER STRAW NEEDLE 305200	272	RC						Both			1	0.45	0.45	0.9	0.65							Fee Schedule		0.74							Fee Schedule																													0.9							Fee Schedule																																															
FILTER VENT  351U5410  ( MEDTRONIC )	270	RC						Both			7.21	3.24	3.24	6.49	4.69							Fee Schedule		5.34							Fee Schedule																													6.49							Fee Schedule																																															
FILTER VENT  351U5856  COVIDIEN	270	RC						Both			7.53	3.39	3.39	6.78	4.89							Fee Schedule		5.57							Fee Schedule																													6.78							Fee Schedule																																															
FILTER VENT PED/ ADULT COVIDIEN 10043551	270	RC						Both			77	34.65	34.65	69.3	50.05							Fee Schedule		56.98							Fee Schedule																													69.3							Fee Schedule																																															
FILTRATION DEVICE LAPARO. 0620-030-100	271	RC						Both			69	31.05	31.05	62.1	44.85							Fee Schedule		51.06							Fee Schedule																													62.1							Fee Schedule																																															
FINASTERIDE 5MG (PROSCAR) TABLET	250	RC	S0138	CPT				Both			7.35	3.31	0.4	6.62	0.4							Fee Schedule		5.44							Fee Schedule																													6.62							Fee Schedule																																															
FINE NEEDLE ASPIRATION	311	RC	88172	CPT				Both			165.9	74.66	13.45	149.31	13.45							Fee Schedule		17.72							Fee Schedule											18.95							Fee Schedule											149.31							Fee Schedule																																															
FINGER LT	320	RC	73140	CPT				Both			315	141.75	11.95	318	20.55							Fee Schedule		24.22							Fee Schedule											11.95							Fee Schedule											283.5							Fee Schedule																				318							Per Diem																				
FINGER RT	320	RC	73140	CPT				Both			315	141.75	11.95	318	20.55							Fee Schedule		24.22							Fee Schedule											11.95							Fee Schedule											283.5							Fee Schedule																				318							Per Diem																				
FINGER SPLINT PLASTILUME # 79-73211	270	RC						Both			3	1.35	1.35	2.7	1.95							Fee Schedule		2.22							Fee Schedule																													2.7							Fee Schedule																																															
FINGER SPLINT TOAD 79-71965	270	RC						Both			3	1.35	1.35	2.7	1.95							Fee Schedule		2.22							Fee Schedule																													2.7							Fee Schedule																																															
FINGER STAX SPLINT #4 79-72254	274	RC						Both			5.25	2.36	2.36	4.73		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	3.89							Fee Schedule																													4.73							Fee Schedule																																															
FINGER STAX SPLINT #5 79-72255	270	RC						Both			4	1.8	1.8	3.6	2.6							Fee Schedule		2.96							Fee Schedule																													3.6							Fee Schedule																																															
FINGER STAX SPLINT #6  79-72257	274	RC	L3808	CPT				Both			3.15	1.42	1.42	386.86		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	2.33							Fee Schedule		386.86							Fee Schedule																				2.84							Fee Schedule																																															
FIRAZYR 30MG/3ML PREFILLED SYRINGE	636	RC	J1744	CPT				Both			36754.2	16539.39	349.3	33078.78		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	27198.11							Fee Schedule																				375.59							Fee Schedule		33078.78							Fee Schedule		431.93							Fee Schedule		349.3							Fee Schedule											431.93							Fee Schedule		349.3							Fee Schedule		
FISTULAGRAM	329	RC	76080	CPT				Both			315	141.75	23.46	318	23.46							Fee Schedule		28.11							Fee Schedule											29.66							Fee Schedule											283.5							Fee Schedule																				318							Per Diem																				
FIXATION NAIL 12MM #456.480S	278	RC	C1713	CPT				Both			7087.5	3189.38	3189.38	6378.75		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	5244.75							Fee Schedule																													6378.75							Fee Schedule																																															
FLAVOXATE 100MG (URISPAS) TABLET	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
FLECAINIDE 50MG (TAMBOCOR) TABLET	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
FLECAINIDE 5309 SERUM	301	RC	80299	CPT				Both			46.2	20.79	13.42	41.58	13.42							Fee Schedule		18.64							Fee Schedule		19.2							Fee Schedule		18.64							Fee Schedule											41.58							Fee Schedule																				18.64							Fee Schedule																				
FLEET PHOSPHO SODA 45ML UD	250	RC	A9270	CPT				Both			13.65	6.14	0.01	21.44	0.01							Fee Schedule		10.1							Fee Schedule																				18.64							Fee Schedule		12.29							Fee Schedule		21.44							Fee Schedule		17.34							Fee Schedule											21.44							Fee Schedule		17.34							Fee Schedule		
FLEET PREP KIT	250	RC	A9270	CPT				Both			29.4	13.23	0.01	26.46	0.01							Fee Schedule		21.76							Fee Schedule																													26.46							Fee Schedule																																															
FLEXIBLE DRILL FOR 1.8MM Q-FIX 72290118	272	RC						Both			450	202.5	202.5	405	292.5							Fee Schedule		333							Fee Schedule																													405							Fee Schedule																																															
FLEXPRESS 2LITE COMP SYSTEM 79200	270	RC						Both			38	17.1	17.1	34.2	24.7							Fee Schedule		28.12							Fee Schedule																													34.2							Fee Schedule																																															
FLOVENT  44 MCG MDI	250	RC	A9270	CPT				Both			599.55	269.8	0.01	539.6	0.01							Fee Schedule		443.67							Fee Schedule																													539.6							Fee Schedule																																															
FLOVENT 110 MCG/PUFF MDI	250	RC	A9270	CPT				Both			543.9	244.76	0.01	489.51	0.01							Fee Schedule		402.49							Fee Schedule																													489.51							Fee Schedule																																															
FLOVENT 250 MCG ROTADISK	250	RC	A9270	CPT				Both			205.6	92.52	0.01	185.04	0.01							Fee Schedule		152.14							Fee Schedule																													185.04							Fee Schedule																																															
FLOW CYTOMETRY	311	RC	88184	CPT				Both			494.55	222.55	43.94	445.1	43.94							Fee Schedule		60.78							Fee Schedule											68.42							Fee Schedule											445.1							Fee Schedule																																															
FLOW CYTOMETRY	311	RC	88184	CPT				Both			494.55	222.55	43.94	445.1	43.94							Fee Schedule		60.78							Fee Schedule											68.42							Fee Schedule											445.1							Fee Schedule																																															
FLOW CYTOMETRY 16 OR MORE MARKERS	311	RC	88189	CPT				Both			494.55	222.55	61.27	445.1	61.27							Fee Schedule		84.54							Fee Schedule											76.75							Fee Schedule											445.1							Fee Schedule																																															
FLOW CYTOMETRY 2 TO 8 MARKERS	311	RC	88187	CPT				Both			494.55	222.55	32.8	445.1	32.8							Fee Schedule		37.3							Fee Schedule											32.98							Fee Schedule											445.1							Fee Schedule																																															
FLOW CYTOMETRY 9 TO 15 MARKERS	311	RC	88188	CPT				Both			494.55	222.55	45.7	445.1	45.7							Fee Schedule		62.89							Fee Schedule											56.5							Fee Schedule											445.1							Fee Schedule																																															
FLOW CYTOMETRY CELL CYCLE DNA	311	RC	88182	CPT				Both			257.25	115.76	60.19	231.53	60.19							Fee Schedule		86.29							Fee Schedule											113.85							Fee Schedule											231.53							Fee Schedule																																															
FLOW CYTOMETRY EACH ADDITIONAL MARKER	311	RC	88185	CPT				Both			225.75	101.59	19.85	203.18	19.85							Fee Schedule		22.41							Fee Schedule											20.83							Fee Schedule											203.18							Fee Schedule																																															
FLOWTRON CALF WRAP MED. 83022B (NEW)	271	RC	C1884	CPT				Both			33	14.85	14.85	134.45	134.45							Fee Schedule		24.42							Fee Schedule																													29.7							Fee Schedule																																															
FLOWTRON CALF WRAP XL 83024B	271	RC	C1884	CPT				Both			62	27.9	27.9	134.45	134.45							Fee Schedule		45.88							Fee Schedule																													55.8							Fee Schedule																																															
FLOWTRON FOOT WRAP 83062B	271	RC	C1884	CPT				Both			57	25.65	25.65	134.45	134.45							Fee Schedule		42.18							Fee Schedule																													51.3							Fee Schedule																																															
FLOXIN 400 MG PREMIX 100 ML	250	RC						Both			86.94	39.12	39.12	78.25	56.51							Fee Schedule		64.34							Fee Schedule																													78.25							Fee Schedule																																															
FLOXIN 400 MG TABLET	250	RC	A9270	CPT				Both			10.65	4.79	0.01	9.59	0.01							Fee Schedule		7.88							Fee Schedule																													9.59							Fee Schedule																																															
FLOXIN OTIC DROPS 5 ML	250	RC	A9270	CPT				Both			189	85.05	0.01	170.1	0.01							Fee Schedule		139.86							Fee Schedule																													170.1							Fee Schedule																																															
FLOXIN:400 MG VIALS	250	RC						Both			83.16	37.42	37.42	74.84	54.05							Fee Schedule		61.54							Fee Schedule																													74.84							Fee Schedule																																															
FLU SHOT > 6 MONTHS	636	RC	90656	CPT				Both			56	25.2	23.91	50.4		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	41.44							Fee Schedule		23.91							Fee Schedule																				50.4							Fee Schedule																																															
FLU SHOT 6-35 MTHS	636	RC	90657	CPT				Both			48.3	21.74	11.37	43.47		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	35.74							Fee Schedule		11.37							Fee Schedule		14.28							Fee Schedule		23.22							Fee Schedule		43.47							Fee Schedule		26.7							Fee Schedule		21.59							Fee Schedule											26.7							Fee Schedule		21.59							Fee Schedule		
FLUBLOK FLU VACCINE 0.5ML	636	RC	90673	CPT				Both			119.86	53.94	10.26	107.87		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	88.7							Fee Schedule		101.1							Fee Schedule											11.03							Fee Schedule		107.87							Fee Schedule		12.69							Fee Schedule		10.26							Fee Schedule											12.69							Fee Schedule		10.26							Fee Schedule		
FLUCONAZOLE 100 MG/50ML (DIFLUCAN) IVPB	636	RC	J1450	CPT				Both			34.65	15.59	6.29	112.88		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	25.64							Fee Schedule		6.29							Fee Schedule											98.16							Fee Schedule		31.19							Fee Schedule		112.88							Fee Schedule		91.29							Fee Schedule											112.88							Fee Schedule		91.29							Fee Schedule		
FLUCONAZOLE 100MG (DIFLUCAN) TABLET	250	RC	A9270	CPT				Both			26.25	11.81	0.01	23.63	0.01							Fee Schedule		19.43							Fee Schedule																				6.11							Fee Schedule		23.63							Fee Schedule		7.02							Fee Schedule		5.68							Fee Schedule											7.02							Fee Schedule		5.68							Fee Schedule		
FLUCONAZOLE 150MG (DIFLUCAN) TABLET	250	RC	A9270	CPT				Both			44.1	19.85	0.01	39.69	0.01							Fee Schedule		32.63							Fee Schedule																													39.69							Fee Schedule																																															
FLUCONAZOLE 200 MG/100ML(DIFLUCAN)PREMIX	636	RC	J1450	CPT				Both			18.9	8.51	6.29	17.01		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	13.99							Fee Schedule		6.29							Fee Schedule																				17.01							Fee Schedule																																															
FLUCONAZOLE 400 MG/200ML(DIFLUCAN)PREMIX	636	RC	J1450	CPT				Both			74.91	33.71	5.68	67.42		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	55.43							Fee Schedule		6.29							Fee Schedule											6.11							Fee Schedule		67.42							Fee Schedule		7.02							Fee Schedule		5.68							Fee Schedule											7.02							Fee Schedule		5.68							Fee Schedule		
FLUCONAZOLE 50MG (DIFLUCAN) TABLET	250	RC	A9270	CPT				Both			17.85	8.03	0.01	16.07	0.01							Fee Schedule		13.21							Fee Schedule																				6.11							Fee Schedule		16.07							Fee Schedule		7.02							Fee Schedule		5.68							Fee Schedule											7.02							Fee Schedule		5.68							Fee Schedule		
FLUDROCORTISONE 0.1MG (FLORINEF) TABLET	250	RC	A9270	CPT				Both			5.25	2.36	0.01	4.73	0.01							Fee Schedule		3.89							Fee Schedule																													4.73							Fee Schedule																																															
FLUENT DISP. TISSUE SOCK FLT-010	270	RC						Both			31	13.95	13.95	27.9	20.15							Fee Schedule		22.94							Fee Schedule																													27.9							Fee Schedule																																															
FLUENT FLUID MANAGE. WASTE BAGS #FLT-005	270	RC						Both			185	83.25	83.25	166.5	120.25							Fee Schedule		136.9							Fee Schedule																													166.5							Fee Schedule																																															
FLUENT FLUID MANAGEMENT SYSTEM FLT-112	270	RC						Both			1197	538.65	538.65	1077.3	778.05							Fee Schedule		885.78							Fee Schedule																													1077.3							Fee Schedule																																															
FLUID WASHING SMEARS	300	RC	88104	CPT				Both			162.75	73.24	28.63	146.48	28.63							Fee Schedule		37.53							Fee Schedule											42.9							Fee Schedule											146.48							Fee Schedule																																															
FLULAVAL INFLUENZA VACCINE	636	RC	90658	CPT				Both			23.1	10.4	10.4	22.73		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	17.09							Fee Schedule		22.73							Fee Schedule		14.28							Fee Schedule											20.79							Fee Schedule																																															
FLUMAZENIL 0.1 MG/ML-10ML	250	RC	J3490	CPT				Both			48.75	21.94	20.52	43.88	31.69							Fee Schedule		36.08							Fee Schedule																				22.07							Fee Schedule		43.88							Fee Schedule		25.38							Fee Schedule		20.52							Fee Schedule											25.38							Fee Schedule		20.52							Fee Schedule		
FLUMAZENIL 0.1 MG/ML-5ML	250	RC	J3490	CPT				Both			24.39	10.98	10.98	21.95	15.85							Fee Schedule		18.05							Fee Schedule																													21.95							Fee Schedule																																															
FLU-MIST NASAL VACCINE (CURRENT YR)	636	RC	90660	CPT				Both			25.25	11.36	11.36	30.61		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	18.69							Fee Schedule		30.61							Fee Schedule																				22.73							Fee Schedule																																															
FLUNISOLIDE 0.025% NASAL SOLUTION	636	RC	J3535	CPT				Both			207.9	93.56	27.63	187.11		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	153.85							Fee Schedule																				29.71							Fee Schedule		187.11							Fee Schedule		34.17							Fee Schedule		27.63							Fee Schedule											34.17							Fee Schedule		27.63							Fee Schedule		
FLUOCINOLONE 0.01% CR-15GM	250	RC	A9270	CPT				Both			141.37	63.62	0.01	127.23	0.01							Fee Schedule		104.61							Fee Schedule																													127.23							Fee Schedule																																															
FLUOCINONIDE 0.05% OINTMENT-15GM	250	RC	A9270	CPT				Both			62.72	28.22	0.01	56.45	0.01							Fee Schedule		46.41							Fee Schedule																													56.45							Fee Schedule																																															
FLUOCINONIDE 0.05% TOPICAL CREAM-15GM	250	RC	A9270	CPT				Both			42	18.9	0.01	37.8	0.01							Fee Schedule		31.08							Fee Schedule																													37.8							Fee Schedule																																															
FLUORIDE 949 SPECIAL COLLECTION	301	RC	82735	CPT				Both			124.95	56.23	16.48	112.46	16.48							Fee Schedule		20.6							Fee Schedule		19.1							Fee Schedule		18.54							Fee Schedule											112.46							Fee Schedule																				18.54							Fee Schedule																				
FLUORO ERCP TIP	272	RC						Both			97.65	43.94	17.24	87.89	63.47							Fee Schedule		72.26							Fee Schedule																				18.54							Fee Schedule		87.89							Fee Schedule		21.32							Fee Schedule		17.24							Fee Schedule											21.32							Fee Schedule		17.24							Fee Schedule		
FLUORO GUIDED NEEDLE PLCMT	320	RC	77002	CPT				Both			315	141.75	34.98	318	54.32							Fee Schedule		67.08							Fee Schedule											34.98							Fee Schedule											283.5							Fee Schedule																				318							Per Diem																				
FLUORO GUIDED NEEDLE PLCMT	320	RC	77003	CPT				Both			270.39	121.68	31.99	318	52.86							Fee Schedule		61.88							Fee Schedule											31.99							Fee Schedule											243.35							Fee Schedule																				318							Per Diem																				
FLUORO ONLY	320	RC	76000	CPT				Both			315	141.75	28.76	318	31.9							Fee Schedule		28.76							Fee Schedule											36.83							Fee Schedule											283.5							Fee Schedule																				318							Per Diem																				
FLUOROMETHOLONE 0.1% OPTH SOLN-5ML	250	RC	A9270	CPT				Both			31.66	14.25	0.01	28.49	0.01							Fee Schedule		23.43							Fee Schedule																													28.49							Fee Schedule																																															
FLUOROPLASTIC VENT EARTUBE(SMITH NEPHEW)	278	RC						Both			25.2	11.34	11.34	22.68		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	18.65							Fee Schedule																													22.68							Fee Schedule																																															
FLUOXETINE 10MG (PROZAC) CAPSULE	250	RC	A9270	CPT				Both			7.26	3.27	0.01	6.53	0.01							Fee Schedule		5.37							Fee Schedule																													6.53							Fee Schedule																																															
FLUoxetine 20MG (PROZAC) CAPSULE	250	RC	A9270	CPT				Both			7.44	3.35	0.01	6.7	0.01							Fee Schedule		5.51							Fee Schedule																													6.7							Fee Schedule																																															
FLUOXETINE 8389 SERUM PROZAC	301	RC	80299	CPT				Both			165.9	74.66	13.42	149.31	13.42							Fee Schedule		18.64							Fee Schedule		19.2							Fee Schedule		18.64							Fee Schedule											149.31							Fee Schedule																				18.64							Fee Schedule																				
FLUPHENAZINE 5 MG TABLET UD	250	RC	A9270	CPT				Both			5.25	2.36	0.01	21.44	0.01							Fee Schedule		3.89							Fee Schedule																				18.64							Fee Schedule		4.73							Fee Schedule		21.44							Fee Schedule		17.34							Fee Schedule											21.44							Fee Schedule		17.34							Fee Schedule		
FLUPHENAZINE 8815 SERUM PROTECT F LIGHT	301	RC	80299	CPT				Both			195.3	87.89	13.42	175.77	13.42							Fee Schedule		18.64							Fee Schedule		19.2							Fee Schedule		18.64							Fee Schedule											175.77							Fee Schedule																				18.64							Fee Schedule																				
FLUPHENAZINE DECANOATE 25 MG/ML-5ML MDV	636	RC	J2680	CPT				Both			48.3	21.74	5.95	43.47		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	35.74							Fee Schedule		5.95							Fee Schedule		19.08							Fee Schedule		18.64							Fee Schedule		43.47							Fee Schedule		21.44							Fee Schedule		17.34							Fee Schedule											21.44							Fee Schedule		17.34							Fee Schedule		
FLURBIPROFEN 0.03%(OCUFEN) OPTH SOLUTION	250	RC	A9270	CPT				Both			136.5	61.43	0.01	122.85	0.01							Fee Schedule		101.01							Fee Schedule																				5.78							Fee Schedule		122.85							Fee Schedule		6.65							Fee Schedule		5.38							Fee Schedule											6.65							Fee Schedule		5.38							Fee Schedule		
FLUSH NS PREFILLED 10ML NONSTER. (FLOOR)	250	RC						Both			1	0.45	0.45	0.9	0.65							Fee Schedule		0.74							Fee Schedule																													0.9							Fee Schedule																																															
FLUSH NS PREFILLED 10ML STERILE (FLOORS)	250	RC	A4216	CPT				Both			3	1.35	0.34	2.7	0.34							Fee Schedule		2.22							Fee Schedule		0.56							Fee Schedule																				2.7							Fee Schedule																																															
FLUSH PREFILLED HEPARIN 5ML 50 USP FLOOR	250	RC						Both			1.35	0.61	0.5	1.22	0.88							Fee Schedule		1							Fee Schedule																				0.54							Fee Schedule		1.22							Fee Schedule		0.62							Fee Schedule		0.5							Fee Schedule											0.62							Fee Schedule		0.5							Fee Schedule		
FLUTAMIDE 125 MG CAPSULE UD	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
FLUTICASONE (FLOVENT) INHALER 220MCG	250	RC	A9270	CPT				Both			831.6	374.22	0.01	748.44	0.01							Fee Schedule		615.38							Fee Schedule																													748.44							Fee Schedule																																															
FLUTICASONE PROPIONATE NASAL SPRAY 50MCG	250	RC	A9270	CPT				Both			268.8	120.96	0.01	241.92	0.01							Fee Schedule		198.91							Fee Schedule																													241.92							Fee Schedule																																															
FLUTTER POCKET PEP DEVICE DR BURTON 530	270	RC						Both			69	31.05	31.05	62.1	44.85							Fee Schedule		51.06							Fee Schedule																													62.1							Fee Schedule																																															
FLUVOXAMINE 100MG TAB	250	RC	A9270	CPT				Both			8	3.6	0.01	7.2	0.01							Fee Schedule		5.92							Fee Schedule																													7.2							Fee Schedule																																															
FLUVOXAMINE 30529 TO NMS LAB SERUM	301	RC	82542	CPT				Both			216.3	97.34	17.34	194.67	17.34							Fee Schedule		24.09							Fee Schedule		24.81							Fee Schedule		24.09							Fee Schedule											194.67							Fee Schedule																				24.09							Fee Schedule																				
FLUZONE HIGH DOSE (FLU VACCINE) 65+	636	RC	90662	CPT				Both			112.89	50.8	22.4	101.6		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	83.54							Fee Schedule		101.1							Fee Schedule											24.09							Fee Schedule		101.6							Fee Schedule		27.7							Fee Schedule		22.4							Fee Schedule											27.7							Fee Schedule		22.4							Fee Schedule		
FML 0.1% OPTHL OINT -3.5GM	250	RC	A9270	CPT				Both			132.62	59.68	0.01	119.36	0.01							Fee Schedule		98.14							Fee Schedule																				98.16							Fee Schedule		119.36							Fee Schedule		112.88							Fee Schedule		91.29							Fee Schedule											112.88							Fee Schedule		91.29							Fee Schedule		
FOAM TRIANGLE WEDGE MEDLINE  NON081245	270	RC	E0190	CPT				Both			20	9	9	35.61	35.61							Fee Schedule		14.8							Fee Schedule																													18							Fee Schedule																																															
FOGARTY CATH #4 FR 120804F	272	RC	C1757	CPT				Both			191	85.95	16.33	171.9	16.33							Fee Schedule		141.34							Fee Schedule																													171.9							Fee Schedule																																															
FOGARTY CATHETER 3 FR. 120803F	272	RC						Both			181.65	81.74	81.74	163.49	118.07							Fee Schedule		134.42							Fee Schedule																													163.49							Fee Schedule																																															
FOGARTY CATHETER 5 FR. 120805F	272	RC						Both			191	85.95	85.95	171.9	124.15							Fee Schedule		141.34							Fee Schedule																													171.9							Fee Schedule																																															
FOL DRAIN BAG URINE	272	RC						Both			49.35	22.21	22.21	44.42	32.08							Fee Schedule		36.52							Fee Schedule																													44.42							Fee Schedule																																															
FOLATE	301	RC	82746	CPT				Both			158.55	71.35	13.07	142.7	13.07							Fee Schedule		16.34							Fee Schedule		15.14							Fee Schedule		14.7							Fee Schedule											142.7							Fee Schedule																				14.7							Fee Schedule																				
FOLEY CATH 10 FR 165810	272	RC	A4338	CPT				Both			21	9.45	9.45	18.9	9.73							Fee Schedule		15.54							Fee Schedule		15.85							Fee Schedule		12.16							Fee Schedule		14.7							Fee Schedule		18.9							Fee Schedule		16.91							Fee Schedule		13.67							Fee Schedule											16.91							Fee Schedule		13.67							Fee Schedule		
FOLEY CATH 10 FR. (DISC.)	272	RC	A4338	CPT				Both			34.65	15.59	9.73	31.19	9.73							Fee Schedule		25.64							Fee Schedule		15.85							Fee Schedule		12.16							Fee Schedule		15.39							Fee Schedule		31.19							Fee Schedule		17.7							Fee Schedule		14.31							Fee Schedule											17.7							Fee Schedule		14.31							Fee Schedule		
FOLEY CATH 12FR SILICONE 2-WAY 10CC DYND	272	RC	A4344	CPT				Both			9	4.05	4.05	21.51	13.19							Fee Schedule		6.66							Fee Schedule		21.51							Fee Schedule		16.49							Fee Schedule		15.39							Fee Schedule		8.1							Fee Schedule		17.7							Fee Schedule		14.31							Fee Schedule											17.7							Fee Schedule		14.31							Fee Schedule		
FOLEY CATH 12FR. (DISC.)	272	RC	A4338	CPT				Both			15.57	7.01	7.01	24.01	9.73							Fee Schedule		11.52							Fee Schedule		15.85							Fee Schedule		12.16							Fee Schedule		20.88							Fee Schedule		14.01							Fee Schedule		24.01							Fee Schedule		19.42							Fee Schedule											24.01							Fee Schedule		19.42							Fee Schedule		
FOLEY CATH 16 FR.30CC BULB 3601	272	RC	A4338	CPT				Both			9	4.05	4.05	17.7	9.73							Fee Schedule		6.66							Fee Schedule		15.85							Fee Schedule		12.16							Fee Schedule		15.39							Fee Schedule		8.1							Fee Schedule		17.7							Fee Schedule		14.31							Fee Schedule											17.7							Fee Schedule		14.31							Fee Schedule		
FOLEY CATH 18  3563	270	RC						Both			68.25	30.71	14.31	61.43	44.36							Fee Schedule		50.51							Fee Schedule																				15.39							Fee Schedule		61.43							Fee Schedule		17.7							Fee Schedule		14.31							Fee Schedule											17.7							Fee Schedule		14.31							Fee Schedule		
FOLEY CATH 18 FR. W/30 CC BULB 3607	272	RC	A4338	CPT				Both			9	4.05	4.05	15.85	9.73							Fee Schedule		6.66							Fee Schedule		15.85							Fee Schedule		12.16							Fee Schedule											8.1							Fee Schedule																																															
FOLEY CATH 20 FR. W/30 CC BULB 3611	272	RC	A4338	CPT				Both			11	4.95	4.95	17.7	9.73							Fee Schedule		8.14							Fee Schedule		15.85							Fee Schedule		12.16							Fee Schedule		15.39							Fee Schedule		9.9							Fee Schedule		17.7							Fee Schedule		14.31							Fee Schedule											17.7							Fee Schedule		14.31							Fee Schedule		
FOLEY CATH 22FR W/30CC BULB	272	RC	A4338	CPT				Both			27.3	12.29	9.73	24.57	9.73							Fee Schedule		20.2							Fee Schedule		15.85							Fee Schedule		12.16							Fee Schedule		15.39							Fee Schedule		24.57							Fee Schedule		17.7							Fee Schedule		14.31							Fee Schedule											17.7							Fee Schedule		14.31							Fee Schedule		
FOLEY CATH 30 FR. W/30 CC BULB	272	RC	A4338	CPT				Both			39.9	17.96	9.73	35.91	9.73							Fee Schedule		29.53							Fee Schedule		15.85							Fee Schedule		12.16							Fee Schedule		15.39							Fee Schedule		35.91							Fee Schedule		17.7							Fee Schedule		14.31							Fee Schedule											17.7							Fee Schedule		14.31							Fee Schedule		
FOLEY CATH 5 FR.	272	RC	A4338	CPT				Both			22.05	9.92	9.73	19.85	9.73							Fee Schedule		16.32							Fee Schedule		15.85							Fee Schedule		12.16							Fee Schedule		15.39							Fee Schedule		19.85							Fee Schedule		17.7							Fee Schedule		14.31							Fee Schedule											17.7							Fee Schedule		14.31							Fee Schedule		
FOLEY CATH TRAY 16 SILVER	272	RC	A4315	CPT				Both			34.65	15.59	14.31	38.72	23.75							Fee Schedule		25.64							Fee Schedule		38.72							Fee Schedule		29.69							Fee Schedule		15.39							Fee Schedule		31.19							Fee Schedule		17.7							Fee Schedule		14.31							Fee Schedule											17.7							Fee Schedule		14.31							Fee Schedule		
FOLEY CATH TRAY 18 SILVER	272	RC						Both			34.65	15.59	15.59	43.23	22.52							Fee Schedule		25.64							Fee Schedule																				37.59							Fee Schedule		31.19							Fee Schedule		43.23							Fee Schedule		34.96							Fee Schedule											43.23							Fee Schedule		34.96							Fee Schedule		
FOLEY CATH W/ TEMP SENSOR 12FR  FC400-12	272	RC						Both			361	162.45	162.45	324.9	234.65							Fee Schedule		267.14							Fee Schedule																													324.9							Fee Schedule																																															
FOLEY CATH W/ TEMP SENSOR 14FR	272	RC						Both			30.18	13.58	13.58	27.16	19.62							Fee Schedule		22.33							Fee Schedule																													27.16							Fee Schedule																																															
FOLEY CATH W/ TEMP SENSOR 16FR	272	RC						Both			59	26.55	26.55	53.1	38.35							Fee Schedule		43.66							Fee Schedule																													53.1							Fee Schedule																																															
FOLEY CATH W/ TEMP SENSOR 18FR	272	RC						Both			30	13.5	13.5	27	19.5							Fee Schedule		22.2							Fee Schedule																													27							Fee Schedule																																															
FOLEY CATH WHISTLE TIP	272	RC	A4340	CPT				Both			13.65	6.14	6.14	46.61	28.59							Fee Schedule		10.1							Fee Schedule		46.61							Fee Schedule		35.74							Fee Schedule											12.29							Fee Schedule																																															
FOLEY CATH WHISTLE TIP BARD #136406	272	RC	A4340	CPT				Both			26.25	11.81	11.81	52.04	28.59							Fee Schedule		19.43							Fee Schedule		46.61							Fee Schedule		35.74							Fee Schedule		45.25							Fee Schedule		23.63							Fee Schedule		52.04							Fee Schedule		42.08							Fee Schedule											52.04							Fee Schedule		42.08							Fee Schedule		
FOLEY CATH. 18FR. 5CC # 605189IC SILVER	272	RC	A4338	CPT				Both			27.3	12.29	9.73	52.04	9.73							Fee Schedule		20.2							Fee Schedule		15.85							Fee Schedule		12.16							Fee Schedule		45.25							Fee Schedule		24.57							Fee Schedule		52.04							Fee Schedule		42.08							Fee Schedule											52.04							Fee Schedule		42.08							Fee Schedule		
FOLEY CATH. 24 FR.5CC # 605247 SILVER	272	RC	A4338	CPT				Both			27.3	12.29	9.73	24.57	9.73							Fee Schedule		20.2							Fee Schedule		15.85							Fee Schedule		12.16							Fee Schedule		15.39							Fee Schedule		24.57							Fee Schedule		17.7							Fee Schedule		14.31							Fee Schedule											17.7							Fee Schedule		14.31							Fee Schedule		
FOLEY CATH.22FR. 5CC #605221 SILVER	272	RC	A4346	CPT				Both			27.3	12.29	12.29	28.75	17.63							Fee Schedule		20.2							Fee Schedule		28.75							Fee Schedule		22.04							Fee Schedule		15.39							Fee Schedule		24.57							Fee Schedule		17.7							Fee Schedule		14.31							Fee Schedule											17.7							Fee Schedule		14.31							Fee Schedule		
FOLEY CATHETER 14 5CC 605148 SILVER	272	RC	A4338	CPT				Both			90.5	40.73	9.73	81.45	9.73							Fee Schedule		66.97							Fee Schedule		15.85							Fee Schedule		12.16							Fee Schedule		27.91							Fee Schedule		81.45							Fee Schedule		32.1							Fee Schedule		25.96							Fee Schedule											32.1							Fee Schedule		25.96							Fee Schedule		
FOLEY CATHETER 16FR. 5CC #605163 SILVER	272	RC	A4338	CPT				Both			27.3	12.29	9.73	24.57	9.73							Fee Schedule		20.2							Fee Schedule		15.85							Fee Schedule		12.16							Fee Schedule		15.39							Fee Schedule		24.57							Fee Schedule		17.7							Fee Schedule		14.31							Fee Schedule											17.7							Fee Schedule		14.31							Fee Schedule		
FOLEY CATHETER COUNCILL 5ML 18F 0196SI18	272	RC	A4338	CPT				Both			91	40.95	9.73	81.9	9.73							Fee Schedule		67.34							Fee Schedule		15.85							Fee Schedule		12.16							Fee Schedule		15.39							Fee Schedule		81.9							Fee Schedule		17.7							Fee Schedule		14.31							Fee Schedule											17.7							Fee Schedule		14.31							Fee Schedule		
FOLEY CATHETER TRAY 14 #DYND160814	272	RC						Both			76	34.2	14.31	68.4	49.4							Fee Schedule		56.24							Fee Schedule																				15.39							Fee Schedule		68.4							Fee Schedule		17.7							Fee Schedule		14.31							Fee Schedule											17.7							Fee Schedule		14.31							Fee Schedule		
FOLEY CATHETER TRAY 16 #DYND160816	270	RC						Both			75	33.75	33.75	67.5	48.75							Fee Schedule		55.5							Fee Schedule																													67.5							Fee Schedule																																															
FOLEY CATHETER TRAY 18 (MEDLINE)	270	RC						Both			73.5	33.08	33.08	66.15	47.78							Fee Schedule		54.39							Fee Schedule																													66.15							Fee Schedule																																															
FOLEY DRAINAGE BAG  6308LL	272	RC						Both			22	9.9	9.9	19.8	14.3							Fee Schedule		16.28							Fee Schedule																													19.8							Fee Schedule																																															
FOLEY TRAY W/O CATH ADD-A- FOLEY 6255 DC	272	RC	A4313	CPT				Both			31	13.95	13.95	27.9	16.68							Fee Schedule		22.94							Fee Schedule		27.19							Fee Schedule		20.85							Fee Schedule											27.9							Fee Schedule																																															
FOLEY TRAY W/O SILVER  BARD	272	RC						Both			17.85	8.03	8.03	30.36	11.6							Fee Schedule		13.21							Fee Schedule																				26.4							Fee Schedule		16.07							Fee Schedule		30.36							Fee Schedule		24.55							Fee Schedule											30.36							Fee Schedule		24.55							Fee Schedule		
FOLEY/CATH/PED/10FR.	272	RC	A4338	CPT				Both			34.65	15.59	9.73	31.19	9.73							Fee Schedule		25.64							Fee Schedule		15.85							Fee Schedule		12.16							Fee Schedule											31.19							Fee Schedule																																															
FOLIC ACID 1 MG TABS	250	RC	A9270	CPT				Both			5.25	2.36	0.01	17.7	0.01							Fee Schedule		3.89							Fee Schedule																				15.39							Fee Schedule		4.73							Fee Schedule		17.7							Fee Schedule		14.31							Fee Schedule											17.7							Fee Schedule		14.31							Fee Schedule		
FOLIC ACID 5 MG/ML MDV	250	RC	J1808	CPT				Both			12	5.4	0.05	10.8	7.8							Fee Schedule		8.88							Fee Schedule		0.05							Fee Schedule																				10.8							Fee Schedule																																															
FOLIC ACID RBC 467 EDTA ROOM TEMP	300	RC	82747	CPT				Both			29.4	13.23	0.05	26.46	15.39							Fee Schedule		19.25							Fee Schedule		18.18							Fee Schedule		17.65							Fee Schedule		0.05							Fee Schedule		26.46							Fee Schedule		0.06							Fee Schedule		0.05							Fee Schedule		17.65							Fee Schedule		0.06							Fee Schedule		0.05							Fee Schedule		
FOMEPIZOLE 1.5 GM/1.5 ML -SDV	636	RC	J1451	CPT				Both			3885	1748.25	6.63	3496.5		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	12.43							Fee Schedule		6.63							Fee Schedule											17.65							Fee Schedule		3496.5							Fee Schedule		20.3							Fee Schedule		16.41							Fee Schedule											20.3							Fee Schedule		16.41							Fee Schedule		
FOOT FILE	250	RC	A9270	CPT				Both			9.01	4.05	0.01	8.11	0.01							Fee Schedule		6.67							Fee Schedule																				6.43							Fee Schedule		8.11							Fee Schedule		7.4							Fee Schedule		5.98							Fee Schedule											7.4							Fee Schedule		5.98							Fee Schedule		
FOOT LT 3V	320	RC	73630	CPT				Both			315	141.75	15.33	318	17.05							Fee Schedule		20.65							Fee Schedule											15.33							Fee Schedule											283.5							Fee Schedule																				318							Per Diem																				
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH CC					330	DRG		Inpatient			52884.98	23798.24	23798.24	23798.24							0		No services performed during 15 month lookback period. 				6990.25	6990.25	6990.25	1 through 10									0		No services performed during 15 month lookback period							0		No services provided during 15 month lookback period				11711.17	11711.17	11711.17	1 through 10									0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period	
FOOT RT 3V	320	RC	73630	CPT				Both			315	141.75	15.33	318	17.05							Fee Schedule		20.65							Fee Schedule											15.33							Fee Schedule											283.5							Fee Schedule																				318							Per Diem																				
FOOTPRINT CARDS  3100-00	271	RC						Both			4	1.8	1.8	3.6	2.6							Fee Schedule		2.96							Fee Schedule																													3.6							Fee Schedule																																															
FORADIL 12 MCG/CAPSULE AEROLIZER	250	RC	A9270	CPT				Both			143.89	64.75	0.01	129.5	0.01							Fee Schedule		106.48							Fee Schedule																													129.5							Fee Schedule																																															
FORANE 250ML	250	RC						Both			441	198.45	198.45	396.9	286.65							Fee Schedule		326.34							Fee Schedule																													396.9							Fee Schedule																																															
FORCEP BIOPSY DISPOSABLE   FB-231D.A	272	RC						Both			88	39.6	39.6	79.2	57.2							Fee Schedule		65.12							Fee Schedule																													79.2							Fee Schedule																																															
FORCEP BIOPSY REUSABLE FB-211D	272	RC						Both			1742	783.9	783.9	1567.8	1132.3							Fee Schedule		1289.08							Fee Schedule																													1567.8							Fee Schedule																																															
FORCEP BIOPSY REUSABLE FB-24U-1	272	RC						Both			945	425.25	425.25	850.5	614.25							Fee Schedule		699.3							Fee Schedule																													850.5							Fee Schedule																																															
FORCEP BRONCH REUSABEL FB-19C-1	272	RC						Both			886.2	398.79	398.79	797.58	576.03							Fee Schedule		655.79							Fee Schedule																													797.58							Fee Schedule																																															
FORCEPS (HOT BIOPSY)	272	RC						Both			1129.8	508.41	508.41	1016.82	734.37							Fee Schedule		836.05							Fee Schedule																													1016.82							Fee Schedule																																															
FOREARM (RAD/ULN) LT	320	RC	73090	CPT				Both			315	141.75	14.14	318	14.14							Fee Schedule		17.72							Fee Schedule											15.04							Fee Schedule											283.5							Fee Schedule																				318							Per Diem																				
FOREARM (RAD/ULN) RT	320	RC	73090	CPT				Both			315	141.75	14.14	318	14.14							Fee Schedule		17.72							Fee Schedule											15.04							Fee Schedule											283.5							Fee Schedule																				318							Per Diem																				
FOREIGN BODY REMOVER # 130811 SCHUKNECT	270	RC						Both			144	64.8	64.8	129.6	93.6							Fee Schedule		106.56							Fee Schedule																													129.6							Fee Schedule																																															
FORTEO 750 MCG/3ML INJECITON	636	RC	J3110	CPT				Both			1716.75	772.54	772.54	1545.08		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1270.4							Fee Schedule																													1545.08							Fee Schedule																																															
FORTRESS 5FR SHEATH 386591 BIOTRONIK	272	RC	C1894	CPT				Both			300	135	87.34	270	87.34							Fee Schedule		222							Fee Schedule																													270							Fee Schedule																																															
FORTRESS 5FR SHEATH 386592 BIOTRONIK	272	RC	C1894	CPT				Both			311.85	140.33	87.34	280.67	87.34							Fee Schedule		230.77							Fee Schedule																													280.67							Fee Schedule																																															
FORTRESS 6FR SHEATH 386593 BIOTRONIK	272	RC	C1894	CPT				Both			311.85	140.33	87.34	280.67	87.34							Fee Schedule		230.77							Fee Schedule																													280.67							Fee Schedule																																															
FORTRESS 6FR SHEATH 386594 BIOTRONIK	272	RC	C1894	CPT				Both			311.85	140.33	87.34	280.67	87.34							Fee Schedule		230.77							Fee Schedule																													280.67							Fee Schedule																																															
FORTRESS 6FR SHEATH 444481 BIOTRONIK	272	RC	C1894	CPT				Both			297	133.65	87.34	267.3	87.34							Fee Schedule		219.78							Fee Schedule																													267.3							Fee Schedule																																															
FORTRESS 6FR SHEATH 444483 BIOTRONIK	272	RC	C1894	CPT				Both			297	133.65	87.34	267.3	87.34							Fee Schedule		219.78							Fee Schedule																													267.3							Fee Schedule																																															
FORTRESS 6FR SHEATH 444484 BIOTRONIK	272	RC	C1894	CPT				Both			297	133.65	87.34	267.3	87.34							Fee Schedule		219.78							Fee Schedule																													267.3							Fee Schedule																																															
FORTRESS 6FR SHEATH 444486 BIOTRONIK	272	RC	C1894	CPT				Both			297	133.65	87.34	267.3	87.34							Fee Schedule		219.78							Fee Schedule																													267.3							Fee Schedule																																															
FORTRESS 7FR SHEATH 452382 BIOTRONIK	272	RC	C1894	CPT				Both			300	135	87.34	270	87.34							Fee Schedule		222							Fee Schedule																													270							Fee Schedule																																															
FORTRESS 7FR SHEATH 452386 BIOTRONIK	272	RC	C1894	CPT				Both			300	135	87.34	270	87.34							Fee Schedule		222							Fee Schedule																													270							Fee Schedule																																															
FORTRESS 8FR SHEATH 452385 BIOTRONIK	272	RC	C1894	CPT				Both			300	135	87.34	270	87.34							Fee Schedule		222							Fee Schedule																													270							Fee Schedule																																															
FORTRESS 8FR SHEATH 452387 BIOTRONIK	272	RC	C1894	CPT				Both			300	135	87.34	270	87.34							Fee Schedule		222							Fee Schedule																													270							Fee Schedule																																															
FOSAMAX 10 MG TABLET UD	250	RC	A9270	CPT				Both			5.47	2.46	0.01	4.92	0.01							Fee Schedule		4.05							Fee Schedule																													4.92							Fee Schedule																																															
FOSAMAX 70 MG TABLET WEEKLY	250	RC	A9270	CPT				Both			46.68	21.01	0.01	42.01	0.01							Fee Schedule		34.54							Fee Schedule																													42.01							Fee Schedule																																															
FOSFOMYCIN TROMETHAMINE PWD FOR SOLN 3GM	636	RC	A9270	CPT				Both			301.2	135.54	135.54	271.08		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	222.89							Fee Schedule																													271.08							Fee Schedule																																															
FOSINOPRIL 10MG (MONOPRIL) TABLET	250	RC	A9270	CPT				Both			5.25	2.36	0.01	4.73	0.01							Fee Schedule		3.89							Fee Schedule																													4.73							Fee Schedule																																															
FOSPHENYTOIN (CEREBYX)1000 MG PE/ NS100	636	RC	Q2009	CPT				Both			375.9	169.16	1.38	338.31		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	2.31							Fee Schedule		1.38							Fee Schedule																				338.31							Fee Schedule																																															
FRACTURE BED PAN #DYNC8522	271	RC	E0276	CPT				Both			2	0.9	0.9	14.64	7.77							Fee Schedule		1.48							Fee Schedule		14.64							Fee Schedule											1.34							Fee Schedule		1.8							Fee Schedule		1.54							Fee Schedule		1.25							Fee Schedule											1.54							Fee Schedule		1.25							Fee Schedule		
FRACTURE ORTHOSIS HUMERA	274	RC	L3960	CPT				Both			1180.2	531.09	13.22	1062.18		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	873.35							Fee Schedule		954.72							Fee Schedule		692.62							Fee Schedule		14.21							Fee Schedule		1062.18							Fee Schedule		16.34							Fee Schedule		13.22							Fee Schedule											16.34							Fee Schedule		13.22							Fee Schedule		
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC					331	DRG		Inpatient			46304.18	20836.88	20836.88	20836.88							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period				5205.23	5205.23	5205.23	1 through 10						8318.88	8318.88	8318.88	1 through 10						46619.7	46619.7	46619.7	1 through 10									0	Fee Schedule	No services provided during 15 month lookback period				5823.04	5823.04	5823.04	1 through 10	Fee Schedule								0		No services provided during 15 month lookback							0	Fee Schedule	No services provided during 15 month lookback period							0	Fee Schedule	No services provided during 15 month lookback period	
PERITONEAL ADHESIOLYSIS WITH MCC					335	DRG		Inpatient			42520.62	19134.28	19134.28	19134.28							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period	
PERITONEAL ADHESIOLYSIS WITH CC					336	DRG		Inpatient			53634.14	24135.36	24135.36	24135.36							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period. 				15052.3	15052.3	15052.3	1 through 10									0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period	
FROG SPLINT # 79-71965	270	RC	A4570	CPT				Both			2	0.9	0.9	17.85	9.08							Fee Schedule		1.48							Fee Schedule											17.85							Fee Schedule											1.8							Fee Schedule																																															
FROZEN SECTION	310	RC	88333	CPT				Both			165.9	74.66	16.25	149.31	16.25							Fee Schedule		22.92							Fee Schedule											28.05							Fee Schedule											149.31							Fee Schedule																																															
FROZEN SECTION DURING SURG EA ADD TISSUE	312	RC	88332	CPT				Both			150.15	67.57	13.91	135.14	13.91							Fee Schedule		19.67							Fee Schedule											21.89							Fee Schedule											135.14							Fee Schedule																																															
FRUCTOSAMINE 8340 1ML SERUM	301	RC	82985	CPT				Both			36.75	16.54	13.4	33.08	13.4							Fee Schedule		16.76							Fee Schedule		17.26							Fee Schedule		16.76							Fee Schedule											33.08							Fee Schedule																				16.76							Fee Schedule																				
FSH  SERUM	301	RC	83001	CPT				Both			165.9	74.66	15.59	149.31	16.52							Fee Schedule		20.65							Fee Schedule		19.14							Fee Schedule		18.58							Fee Schedule		16.76							Fee Schedule		149.31							Fee Schedule		19.27							Fee Schedule		15.59							Fee Schedule		18.58							Fee Schedule		19.27							Fee Schedule		15.59							Fee Schedule		
FTA ABS 4112 SERUM	302	RC	86780	CPT				Both			73.5	33.08	11.76	66.15	11.76							Fee Schedule		14.71							Fee Schedule		13.64							Fee Schedule		13.24							Fee Schedule		18.58							Fee Schedule		66.15							Fee Schedule		21.37							Fee Schedule		17.28							Fee Schedule		13.24							Fee Schedule		21.37							Fee Schedule		17.28							Fee Schedule		
FULL RADIUS BLADE 2.0MM #72201507	272	RC						Both			162.75	73.24	12.31	146.48	105.79							Fee Schedule		120.44							Fee Schedule																				13.24							Fee Schedule		146.48							Fee Schedule		15.23							Fee Schedule		12.31							Fee Schedule											15.23							Fee Schedule		12.31							Fee Schedule		
FULL RADIUS BLADE 3.5MM #72201510	272	RC						Both			162.75	73.24	73.24	146.48	105.79							Fee Schedule		120.44							Fee Schedule																													146.48							Fee Schedule																																															
FULL RADIUS BLADE 4.5   3443 SMITHNEPHEW	272	RC						Both			202.65	91.19	91.19	182.39	131.72							Fee Schedule		149.96							Fee Schedule																													182.39							Fee Schedule																																															
FULL RADIUS BLADE 5.5   3444 SMITHNEPHEW	272	RC						Both			202.65	91.19	91.19	182.39	131.72							Fee Schedule		149.96							Fee Schedule																													182.39							Fee Schedule																																															
FULL RADUIS BLADE 4.5	272	RC						Both			202.65	91.19	91.19	182.39	131.72							Fee Schedule		149.96							Fee Schedule																													182.39							Fee Schedule																																															
PERITONEAL ADHESIOLYSIS WITHOUT CC/MCC					337	DRG		Inpatient			49096.63	22093.48	22093.48	22093.48							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period	
FUNGIZONE 50 MG	636	RC	J0285	CPT				Both			102.38	46.07	43.18	119.97		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	75.76							Fee Schedule		43.18							Fee Schedule		119.97							Fee Schedule											92.14							Fee Schedule																																															
FUNGUS AB PANEL 1  (7649) 2ML SERUM	302	RC	86606	CPT				Both			142.8	64.26	13.38	128.52	13.38							Fee Schedule		16.73							Fee Schedule		15.5							Fee Schedule		15.05							Fee Schedule		41.92							Fee Schedule		128.52							Fee Schedule		48.21							Fee Schedule		38.98							Fee Schedule		15.05							Fee Schedule		48.21							Fee Schedule		38.98							Fee Schedule		
FURACIN OINT -56GM	250	RC	A9270	CPT				Both			40.57	18.26	0.01	36.51	0.01							Fee Schedule		30.02							Fee Schedule																				15.05							Fee Schedule		36.51							Fee Schedule		17.31							Fee Schedule		14							Fee Schedule											17.31							Fee Schedule		14							Fee Schedule		
FUROSEMIDE  10 MG/ML ORAL SOLN-60ML	250	RC	A9270	CPT				Both			26.55	11.95	0.01	23.9	0.01							Fee Schedule		19.65							Fee Schedule																													23.9							Fee Schedule																																															
FUROSEMIDE 100 MG/10ML(LASIX) INJECTION	636	RC	J1938	CPT				Both			11.55	5.2	0.02	10.4		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	8.55							Fee Schedule		0.02							Fee Schedule																				10.4							Fee Schedule																																															
FUROSEMIDE 20MG (LASIX) TABLET	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																				0.02							Fee Schedule		5.67							Fee Schedule		0.02							Fee Schedule		0.02							Fee Schedule											0.02							Fee Schedule		0.02							Fee Schedule		
FUROSEMIDE 20MG/2ML (LASIX) INJECTION	636	RC	J1938	CPT				Both			12.6	5.67	0.02	11.34		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	9.32							Fee Schedule		0.02							Fee Schedule																				11.34							Fee Schedule																																															
FUROSEMIDE 40MG (LASIX) TABLET	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																				0.02							Fee Schedule		5.67							Fee Schedule		0.02							Fee Schedule		0.02							Fee Schedule											0.02							Fee Schedule		0.02							Fee Schedule		
FUROSEMIDE 40MG/4ML (LASIX) INJECTION	636	RC	J1938	CPT				Both			12.6	5.67	0.02	11.34		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	9.32							Fee Schedule		0.02							Fee Schedule																				11.34							Fee Schedule																																															
FUROSEMIDE 40MG/4ML(LASIX) SOLUTION  UD	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																				0.02							Fee Schedule		5.67							Fee Schedule		0.02							Fee Schedule		0.02							Fee Schedule											0.02							Fee Schedule		0.02							Fee Schedule		
FUROSEMIDE 50MG/NS 50ML IVPB	250	RC	J1938	CPT				Both			16.8	7.56	0.02	15.12	10.92							Fee Schedule		12.43							Fee Schedule		0.02							Fee Schedule																				15.12							Fee Schedule																																															
FUROSEMIDE 80MG (LASIX) TABLET	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																				0.02							Fee Schedule		5.67							Fee Schedule		0.02							Fee Schedule		0.02							Fee Schedule											0.02							Fee Schedule		0.02							Fee Schedule		
FUSION LITHOTRIPTOR BASKET FS-LXB-3X6	272	RC						Both			941.85	423.83	423.83	847.67	612.2							Fee Schedule		696.97							Fee Schedule																													847.67							Fee Schedule																																															
G C  BY DNA PROBE 11362	306	RC	86631	CPT				Both			68.25	30.71	10.51	61.43	10.51							Fee Schedule		13.14							Fee Schedule		12.17							Fee Schedule		11.82							Fee Schedule											61.43							Fee Schedule																				11.82							Fee Schedule																				
G0009-ADMIN OF PNEUMOCOCCAL VACCINE	771	RC	G0009	CPT				Both			94.5	42.53	4.06	85.05	7.68							Fee Schedule		69.93							Fee Schedule		49.28							Fee Schedule		4.06							Fee Schedule		11.82							Fee Schedule		85.05							Fee Schedule		13.59							Fee Schedule		10.99							Fee Schedule											13.59							Fee Schedule		10.99							Fee Schedule		
G0463- WOUND CARE CLINIC VISIT	519	RC	G0463	CPT				Both			150	67.5	44.49	140.1	74.74							Fee Schedule		111							Fee Schedule		140.1							Fee Schedule											47.84							Fee Schedule		135							Fee Schedule		55.02							Fee Schedule		44.49							Fee Schedule											55.02							Fee Schedule		44.49							Fee Schedule		
GABAPENTIN 100MG (NEURONTIN) CAPSULE	250	RC	A9270	CPT				Both			6.3	2.84	0.01	156.42	0.01							Fee Schedule		4.66							Fee Schedule																				136.02							Fee Schedule		5.67							Fee Schedule		156.42							Fee Schedule		126.5							Fee Schedule											156.42							Fee Schedule		126.5							Fee Schedule		
GABAPENTIN 300MG (NEURONTIN) CAPSULE	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
GABAPENTIN 3557 SERUM	301	RC	80299	CPT				Both			186.9	84.11	13.42	168.21	13.42							Fee Schedule		18.64							Fee Schedule		19.2							Fee Schedule		18.64							Fee Schedule											168.21							Fee Schedule																				18.64							Fee Schedule																				
GABAPENTIN 400MG (NEURONTIN) CAPSULE	250	RC	A9270	CPT				Both			6.3	2.84	0.01	21.44	0.01							Fee Schedule		4.66							Fee Schedule																				18.64							Fee Schedule		5.67							Fee Schedule		21.44							Fee Schedule		17.34							Fee Schedule											21.44							Fee Schedule		17.34							Fee Schedule		
GABITRIL 2 MG TABLET	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
GAD 65 ANTIBODY 34878 SERUM 1ML	301	RC	83519	CPT				Both			156.45	70.4	13.25	140.81	13.25							Fee Schedule		18.4							Fee Schedule		18.95							Fee Schedule		18.4							Fee Schedule											140.81							Fee Schedule																				18.4							Fee Schedule																				
G-ADMIN	771	RC						Both			94.5	42.53	17.11	85.05	61.43							Fee Schedule		69.93							Fee Schedule																				18.4							Fee Schedule		85.05							Fee Schedule		21.16							Fee Schedule		17.11							Fee Schedule											21.16							Fee Schedule		17.11							Fee Schedule		
"GALACTOSE-ALPHA-1,3 GALC IGE 10554"	302	RC	86008	CPT				Both			69	31.05	15.94	62.1	15.94							Fee Schedule		19.93							Fee Schedule		18.47							Fee Schedule		17.93							Fee Schedule											62.1							Fee Schedule																				17.93							Fee Schedule																				
GAMIMUNE N 10%  2.5 GM/25ML VIAL	636	RC	J1568	CPT				Both			433.13	194.91	16.67	389.82		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	47.03							Fee Schedule		48.81							Fee Schedule											17.93							Fee Schedule		389.82							Fee Schedule		20.62							Fee Schedule		16.67							Fee Schedule											20.62							Fee Schedule		16.67							Fee Schedule		
"GAMMA HYDROXYBUTYRIC ACID, SERUM 37654"	301	RC	80307	CPT				Both			342	153.9	44.07	307.8	51.72							Fee Schedule		64.65							Fee Schedule		64							Fee Schedule		62.14							Fee Schedule		47.39							Fee Schedule		307.8							Fee Schedule		54.49							Fee Schedule		44.07							Fee Schedule		62.14							Fee Schedule		54.49							Fee Schedule		44.07							Fee Schedule		
GAMMA NAIL  LAG SCREW	278	RC						Both			786.45	353.9	57.79	707.81		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	581.97							Fee Schedule																				62.14							Fee Schedule		707.81							Fee Schedule		71.46							Fee Schedule		57.79							Fee Schedule											71.46							Fee Schedule		57.79							Fee Schedule		
GAMMA NAIL  LOCKING NAIL 135 DEGREE RIGH	278	RC	C1713	CPT				Both			3388.35	1524.76	1524.76	3049.52		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	2507.38							Fee Schedule																													3049.52							Fee Schedule																																															
GAMMA NAIL  SET SCREW	278	RC						Both			298.2	134.19	134.19	268.38		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	220.67							Fee Schedule																													268.38							Fee Schedule																																															
GAMMAGARD 10%  5GMS/50 ML	636	RC	J1569	CPT				Both			2199.75	989.89	48.71	1979.78		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	49.08							Fee Schedule		48.71							Fee Schedule																				1979.78							Fee Schedule																																															
GAMMAGARD 10% 10 GM/100ML VIAL	636	RC	J1569	CPT				Both			4702.7	2116.22	43.98	4232.43		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	49.08							Fee Schedule		48.71							Fee Schedule											47.29							Fee Schedule		4232.43							Fee Schedule		54.38							Fee Schedule		43.98							Fee Schedule											54.38							Fee Schedule		43.98							Fee Schedule		
GAMMAGLOBULIN 7577 SERUM	301	RC	82784	CPT				Both			52.5	23.63	8.27	54.38	8.27							Fee Schedule		10.34							Fee Schedule		9.58							Fee Schedule		9.3							Fee Schedule		47.29							Fee Schedule		47.25							Fee Schedule		54.38							Fee Schedule		43.98							Fee Schedule		9.3							Fee Schedule		54.38							Fee Schedule		43.98							Fee Schedule		
GAMUNEX 10% 10 GM/100ML VIAL	636	RC	J1561	CPT				Both			3472.88	1562.8	8.65	3125.59		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	49.72							Fee Schedule		50.55							Fee Schedule											9.3							Fee Schedule		3125.59							Fee Schedule		10.7							Fee Schedule		8.65							Fee Schedule											10.7							Fee Schedule		8.65							Fee Schedule		
GAMUNEX 10% 20 GM/200ML VIAL	636	RC	J1561	CPT				Both			6793.5	3057.08	45.64	6114.15		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	49.72							Fee Schedule		50.55							Fee Schedule											49.08							Fee Schedule		6114.15							Fee Schedule		56.44							Fee Schedule		45.64							Fee Schedule											56.44							Fee Schedule		45.64							Fee Schedule		
GANGLIOSIDE GM-1 AB IGG 18951	301	RC	83520	CPT				Both			98	44.1	12.43	88.2	12.43							Fee Schedule		17.27							Fee Schedule		17.79							Fee Schedule		17.27							Fee Schedule		49.08							Fee Schedule		88.2							Fee Schedule		56.44							Fee Schedule		45.64							Fee Schedule		17.27							Fee Schedule		56.44							Fee Schedule		45.64							Fee Schedule		
GARAMYCIN 0.1% OINT	250	RC	A9270	CPT				Both			9.77	4.4	0.01	19.86	0.01							Fee Schedule		7.23							Fee Schedule																				17.27							Fee Schedule		8.79							Fee Schedule		19.86							Fee Schedule		16.06							Fee Schedule											19.86							Fee Schedule		16.06							Fee Schedule		
GARAMYCIN 0.1% OINT.	250	RC	A9270	CPT				Both			12.6	5.67	0.01	11.34	0.01							Fee Schedule		9.32							Fee Schedule																													11.34							Fee Schedule																																															
GARAMYCIN 80MG/2CC	636	RC	J1580	CPT				Both			6.3	2.84	1.98	5.67		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	4.66							Fee Schedule		1.98							Fee Schedule		2.76							Fee Schedule											5.67							Fee Schedule																																															
GARDASIL VACCINE (HPV) 1SINGLE DOSE VIAL	636	RC	90649	CPT				Both			153.3	68.99	1.79	137.97		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	113.44							Fee Schedule																				1.93							Fee Schedule		137.97							Fee Schedule		2.21							Fee Schedule		1.79							Fee Schedule											2.21							Fee Schedule		1.79							Fee Schedule		
GARDASIL-9 VACCINE (HPV) 0.5ML	636	RC	90651	CPT				Both			235.2	105.84	105.84	211.68		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	174.05							Fee Schedule																													211.68							Fee Schedule																																															
GAS SAMPLING LINE #DYNJAA04	270	RC						Both			2	0.9	0.9	1.8	1.3							Fee Schedule		1.48							Fee Schedule																													1.8							Fee Schedule																																															
GASTRIN 478 1ML FRZ SERUM	301	RC	82941	CPT				Both			109.2	49.14	15.67	98.28	15.67							Fee Schedule		19.59							Fee Schedule		18.16							Fee Schedule		17.63							Fee Schedule											98.28							Fee Schedule																				17.63							Fee Schedule																				
GASTRO FEEDING TUBE 8250-18	272	RC						Both			753	338.85	16.4	677.7	489.45							Fee Schedule		557.22							Fee Schedule																				17.63							Fee Schedule		677.7							Fee Schedule		20.27							Fee Schedule		16.4							Fee Schedule											20.27							Fee Schedule		16.4							Fee Schedule		
GASTRO FEEDING TUBE 8250-22	272	RC						Both			746	335.7	335.7	671.4	484.9							Fee Schedule		552.04							Fee Schedule																													671.4							Fee Schedule																																															
GASTROGRAFIN 120ML 0270-004540	270	RC	Q9963	CPT				Both			64	28.8	0.2	57.6	0.2							Fee Schedule		47.36							Fee Schedule		0.22							Fee Schedule																				57.6							Fee Schedule																																															
GASTROGRAFIN CHALLENGE	320	RC	74250	CPT				Both			315	141.75	0.2	318	65.38							Fee Schedule		81.37							Fee Schedule											36.83							Fee Schedule		0.21							Fee Schedule		283.5							Fee Schedule		0.25							Fee Schedule		0.2							Fee Schedule		318							Per Diem		0.25							Fee Schedule		0.2							Fee Schedule		
MINOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC					346	DRG		Inpatient			22322.03	10044.91	10044.91	10044.91							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period	
ANAL AND STOMAL PROCEDURES WITH CC					348	DRG		Inpatient			37979.15	17090.62	17090.62	17090.62							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period	
ANAL AND STOMAL PROCEDURES WITHOUT CC/MCC					349	DRG		Inpatient			22354.35	10059.46	10059.46	10059.46							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period	
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITH MCC					353	DRG		Inpatient			113329.96	50998.48	50998.48	50998.48							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback				21309.92	21309.92	21309.92	1 through 10									0		No services provided during 15 month lookback period	
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITH CC					354	DRG		Inpatient			36387.88	16374.55	16374.55	16374.55							0		No services performed during 15 month lookback period. 				11880.51	11880.51	11880.51	1 through 10									0		No services performed during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period	
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITHOUT CC/MCC					355	DRG		Inpatient			38251.85	17213.33	17213.33	17213.33				19027.24	19027.24	19027.24	1 through 10									0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period				5788.77	5788.77	5788.77	1 through 10									0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period	
GASTROINTESTINAL PATHOGEN PNL PCR 38470	306	RC	87506	CPT				Both			1149.42	517.24	189.71	1034.48	189.71							Fee Schedule		262.99							Fee Schedule		270.88							Fee Schedule		262.99							Fee Schedule											1034.48							Fee Schedule																				262.99							Fee Schedule																				
GASTROSTOMY KIT	272	RC						Both			300.3	135.14	135.14	302.44	195.2							Fee Schedule		222.22							Fee Schedule																				262.99							Fee Schedule		270.27							Fee Schedule		302.44							Fee Schedule		244.58							Fee Schedule											302.44							Fee Schedule		244.58							Fee Schedule		
GASTROSTOMY TUBE 18 FR.	272	RC						Both			367.5	165.38	165.38	330.75	238.88							Fee Schedule		271.95							Fee Schedule																													330.75							Fee Schedule																																															
GASTROSTOMY TUBE 20 FR.ROSS #51364	272	RC	B4087	CPT				Both			78.75	35.44	14.31	70.88	14.31							Fee Schedule		58.28							Fee Schedule																													70.88							Fee Schedule																																															
GAVISCON PER OZ	250	RC	A9270	CPT				Both			1.76	0.79	0.01	1.58	0.01							Fee Schedule		1.3							Fee Schedule																													1.58							Fee Schedule																																															
GAVISCON SUSPENSION	250	RC	A9270	CPT				Both			5.25	2.36	0.01	4.73	0.01							Fee Schedule		3.89							Fee Schedule																													4.73							Fee Schedule																																															
GAVISCON TABLETS	250	RC	A9270	CPT				Both			5.25	2.36	0.01	4.73	0.01							Fee Schedule		3.89							Fee Schedule																													4.73							Fee Schedule																																															
GB ORAL CHOLECYSTO	320	RC	74290	CPT				Both			315	141.75	20.94	318	43.84							Fee Schedule		54.74							Fee Schedule											20.94							Fee Schedule											283.5							Fee Schedule																				318							Per Diem																				
GC COLUMN #536009-001	270	RC						Both			229.95	103.48	103.48	206.96	149.47							Fee Schedule		170.16							Fee Schedule																													206.96							Fee Schedule																																															
GC URINE 11362 URINE SP TUBE	306	RC	87491	CPT				Both			189	85.05	31.2	170.1	31.2							Fee Schedule		38.99							Fee Schedule		36.14							Fee Schedule		35.09							Fee Schedule											170.1							Fee Schedule																				35.09							Fee Schedule																				
GEL HEEL PAD Q93-1873	274	RC	L3808	CPT				Both			422.1	189.95	32.63	386.86		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	312.35							Fee Schedule		386.86							Fee Schedule											35.09							Fee Schedule		379.89							Fee Schedule		40.35							Fee Schedule		32.63							Fee Schedule											40.35							Fee Schedule		32.63							Fee Schedule		
GEL METATARSAL PAD #SLS10465	270	RC	L3050	CPT				Both			47	21.15	21.15	431.93	23.42							Fee Schedule		34.78							Fee Schedule		59.89							Fee Schedule		45.93							Fee Schedule		375.59							Fee Schedule		42.3							Fee Schedule		431.93							Fee Schedule		349.3							Fee Schedule											431.93							Fee Schedule		349.3							Fee Schedule		
GELECAST (UNIBOOT)	271	RC						Both			28.35	12.76	12.76	66.87	18.43							Fee Schedule		20.98							Fee Schedule																				58.15							Fee Schedule		25.52							Fee Schedule		66.87							Fee Schedule		54.08							Fee Schedule											66.87							Fee Schedule		54.08							Fee Schedule		
GELFOAM DRESSING	272	RC						Both			31.5	14.18	14.18	28.35	20.48							Fee Schedule		23.31							Fee Schedule																													28.35							Fee Schedule																																															
GELFOAM DSG. 100CM # 09034201	272	RC	A6251	CPT				Both			210	94.5	1.79	189	1.79							Fee Schedule		155.4							Fee Schedule		2.93							Fee Schedule		2.24							Fee Schedule											189							Fee Schedule																																															
GELSYN-3 16.8MG/2ML SYRINGE	636	RC	J7328	CPT				Both			1304.1	586.85	0.68	1173.69		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	0.68							Fee Schedule		0.69							Fee Schedule											2.84							Fee Schedule		1173.69							Fee Schedule		3.27							Fee Schedule		2.64							Fee Schedule											3.27							Fee Schedule		2.64							Fee Schedule		
GEMFIBROZIL 600MG (LOPID) TABLET	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																				0.67							Fee Schedule		5.67							Fee Schedule		0.77							Fee Schedule		0.63							Fee Schedule											0.77							Fee Schedule		0.63							Fee Schedule		
GENOMIC SEQ ANALYSIS PANEL	310	RC	81450	CPT				Both			1960	882	546.86	1764	546.86							Fee Schedule		759.53							Fee Schedule		782.32							Fee Schedule		759.53							Fee Schedule											1764							Fee Schedule																																															
GENTAK 0.3% OPTHL OINT(GENTAMICIN)-3.5GM	250	RC	A9270	CPT				Both			61.96	27.88	0.01	873.46	0.01							Fee Schedule		45.85							Fee Schedule																				759.53							Fee Schedule		55.76							Fee Schedule		873.46							Fee Schedule		706.36							Fee Schedule											873.46							Fee Schedule		706.36							Fee Schedule		
GENTAMICIN  60 MG/NS 50ML PREMIX IVPB	636	RC	J1580	CPT				Both			12.6	5.67	1.98	11.34		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	9.32							Fee Schedule		1.98							Fee Schedule		2.76							Fee Schedule											11.34							Fee Schedule																																															
GENTAMICIN  80 MG/100ML PREMIX IVPB	636	RC	J1580	CPT				Both			12.6	5.67	1.79	11.34		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	9.32							Fee Schedule		1.98							Fee Schedule		2.76							Fee Schedule		1.93							Fee Schedule		11.34							Fee Schedule		2.21							Fee Schedule		1.79							Fee Schedule											2.21							Fee Schedule		1.79							Fee Schedule		
GENTAMICIN : 20 MG/2ML VIA SYRINGE PUMP	636	RC	J1580	CPT				Both			22.2	9.99	1.79	19.98		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	16.43							Fee Schedule		1.98							Fee Schedule		2.76							Fee Schedule		1.93							Fee Schedule		19.98							Fee Schedule		2.21							Fee Schedule		1.79							Fee Schedule											2.21							Fee Schedule		1.79							Fee Schedule		
GENTAMICIN : 80 MG/2ML INJECTION	636	RC	J1580	CPT				Both			12.6	5.67	1.79	11.34		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	9.32							Fee Schedule		1.98							Fee Schedule		2.76							Fee Schedule		1.93							Fee Schedule		11.34							Fee Schedule		2.21							Fee Schedule		1.79							Fee Schedule											2.21							Fee Schedule		1.79							Fee Schedule		
GENTAMICIN 0.1% TOPICAL CREAM-15GM TUBE	250	RC	A9270	CPT				Both			11.34	5.1	0.01	10.21	0.01							Fee Schedule		8.39							Fee Schedule																				1.93							Fee Schedule		10.21							Fee Schedule		2.21							Fee Schedule		1.79							Fee Schedule											2.21							Fee Schedule		1.79							Fee Schedule		
GENTAMICIN 0.3% OPTHL SOLN- 5ML	250	RC	A9270	CPT				Both			68.25	30.71	0.01	61.43	0.01							Fee Schedule		50.51							Fee Schedule																													61.43							Fee Schedule																																															
GENTAMICIN 100 MG/100ML PREMIX IVPB	636	RC	J1580	CPT				Both			14.7	6.62	1.98	13.23		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	10.88							Fee Schedule		1.98							Fee Schedule		2.76							Fee Schedule											13.23							Fee Schedule																																															
GENTAMICIN 120 MG/100ML PREMIX IVPB	636	RC	J1580	CPT				Both			14.7	6.62	1.79	13.23		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	10.88							Fee Schedule		1.98							Fee Schedule		2.76							Fee Schedule		1.93							Fee Schedule		13.23							Fee Schedule		2.21							Fee Schedule		1.79							Fee Schedule											2.21							Fee Schedule		1.79							Fee Schedule		
GENTAMICIN 140 MG/100ML IVPB	636	RC	J1580	CPT				Both			14.7	6.62	1.79	13.23		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	10.88							Fee Schedule		1.98							Fee Schedule		2.76							Fee Schedule		1.93							Fee Schedule		13.23							Fee Schedule		2.21							Fee Schedule		1.79							Fee Schedule											2.21							Fee Schedule		1.79							Fee Schedule		
GENTAMICIN 160 MG/100ML  IVPB	636	RC	J1580	CPT				Both			14.7	6.62	1.79	13.23		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	10.88							Fee Schedule		1.98							Fee Schedule		2.76							Fee Schedule		1.93							Fee Schedule		13.23							Fee Schedule		2.21							Fee Schedule		1.79							Fee Schedule											2.21							Fee Schedule		1.79							Fee Schedule		
GENTAMICIN 20 MG/2ML VIAL	636	RC	J1580	CPT				Both			22.2	9.99	1.79	19.98		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	16.43							Fee Schedule		1.98							Fee Schedule		2.76							Fee Schedule		1.93							Fee Schedule		19.98							Fee Schedule		2.21							Fee Schedule		1.79							Fee Schedule											2.21							Fee Schedule		1.79							Fee Schedule		
GENTAMICIN 500MG/NS 100ML  IVPB	636	RC	J1580	CPT				Both			31.5	14.18	1.79	28.35		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	23.31							Fee Schedule		1.98							Fee Schedule		2.76							Fee Schedule		1.93							Fee Schedule		28.35							Fee Schedule		2.21							Fee Schedule		1.79							Fee Schedule											2.21							Fee Schedule		1.79							Fee Schedule		
GENTAMICIN PEAK	301	RC	80170	CPT				Both			109.2	49.14	1.79	98.28	14.56							Fee Schedule		18.2							Fee Schedule		16.87							Fee Schedule		16.38							Fee Schedule		1.93							Fee Schedule		98.28							Fee Schedule		2.21							Fee Schedule		1.79							Fee Schedule		16.38							Fee Schedule		2.21							Fee Schedule		1.79							Fee Schedule		
GENTAMICIN RANDOM	301	RC	80170	CPT				Both			109.2	49.14	14.56	98.28	14.56							Fee Schedule		18.2							Fee Schedule		16.87							Fee Schedule		16.38							Fee Schedule		16.38							Fee Schedule		98.28							Fee Schedule		18.84							Fee Schedule		15.23							Fee Schedule		16.38							Fee Schedule		18.84							Fee Schedule		15.23							Fee Schedule		
GENTAMICIN TROUGH	301	RC	80170	CPT				Both			109.2	49.14	14.56	98.28	14.56							Fee Schedule		18.2							Fee Schedule		16.87							Fee Schedule		16.38							Fee Schedule		16.38							Fee Schedule		98.28							Fee Schedule		18.84							Fee Schedule		15.23							Fee Schedule		16.38							Fee Schedule		18.84							Fee Schedule		15.23							Fee Schedule		
GENTAMICIN VIA SYRINGE PUMP	636	RC	J1580	CPT				Both			11.55	5.2	1.98	18.84		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	8.55							Fee Schedule		1.98							Fee Schedule		2.76							Fee Schedule		16.38							Fee Schedule		10.4							Fee Schedule		18.84							Fee Schedule		15.23							Fee Schedule											18.84							Fee Schedule		15.23							Fee Schedule		
GENTAMYCIN 100MG/100ML PREMIX	636	RC	J1580	CPT				Both			19.95	8.98	1.79	17.96		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	14.76							Fee Schedule		1.98							Fee Schedule		2.76							Fee Schedule		1.93							Fee Schedule		17.96							Fee Schedule		2.21							Fee Schedule		1.79							Fee Schedule											2.21							Fee Schedule		1.79							Fee Schedule		
GENTIAN VIOLET SOLUTION	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																				1.93							Fee Schedule		5.67							Fee Schedule		2.21							Fee Schedule		1.79							Fee Schedule											2.21							Fee Schedule		1.79							Fee Schedule		
GENUTRAIN SIZE 1	274	RC	L1820	CPT				Both			157.5	70.88	70.88	153.46		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	116.55							Fee Schedule		153.46							Fee Schedule		117.67							Fee Schedule											141.75							Fee Schedule																																															
GENUTRAIN SIZE 2	274	RC	L1820	CPT				Both			157.5	70.88	70.88	171.34		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	116.55							Fee Schedule		153.46							Fee Schedule		117.67							Fee Schedule		148.99							Fee Schedule		141.75							Fee Schedule		171.34							Fee Schedule		138.56							Fee Schedule											171.34							Fee Schedule		138.56							Fee Schedule		
GENUTRAIN SIZE 3	274	RC	L1820	CPT				Both			157.5	70.88	70.88	171.34		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	116.55							Fee Schedule		153.46							Fee Schedule		117.67							Fee Schedule		148.99							Fee Schedule		141.75							Fee Schedule		171.34							Fee Schedule		138.56							Fee Schedule											171.34							Fee Schedule		138.56							Fee Schedule		
GENUTRAIN SIZE 4	274	RC	L1820	CPT				Both			157.5	70.88	70.88	171.34		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	116.55							Fee Schedule		153.46							Fee Schedule		117.67							Fee Schedule		148.99							Fee Schedule		141.75							Fee Schedule		171.34							Fee Schedule		138.56							Fee Schedule											171.34							Fee Schedule		138.56							Fee Schedule		
GENUTRAIN SIZE 5	272	RC						Both			157.5	70.88	70.88	171.34	102.38							Fee Schedule		116.55							Fee Schedule																				148.99							Fee Schedule		141.75							Fee Schedule		171.34							Fee Schedule		138.56							Fee Schedule											171.34							Fee Schedule		138.56							Fee Schedule		
GENUTRAIN SIZE 6	272	RC						Both			157.5	70.88	70.88	141.75	102.38							Fee Schedule		116.55							Fee Schedule																													141.75							Fee Schedule																																															
GENZYME SWITCH BLADE CURVED METZ 89-5100	272	RC						Both			152.25	68.51	68.51	137.03	98.96							Fee Schedule		112.67							Fee Schedule																													137.03							Fee Schedule																																															
GEODON 60 MG TABLET	250	RC	A9270	CPT				Both			21	9.45	0.01	18.9	0.01							Fee Schedule		15.54							Fee Schedule																													18.9							Fee Schedule																																															
GERI-VITE ELIXIR 473ML	250	RC	A9270	CPT				Both			82.95	37.33	0.01	74.66	0.01							Fee Schedule		61.38							Fee Schedule																													74.66							Fee Schedule																																															
GETING ASSURE CEMIPACK 61301605836	270	RC						Both			10	4.5	4.5	9	6.5							Fee Schedule		7.4							Fee Schedule																													9							Fee Schedule																																															
GETINGE FORTRESS 4 FR 1358815	272	RC	C1757	CPT				Both			311.85	140.33	16.33	280.67	16.33							Fee Schedule		230.77							Fee Schedule																													280.67							Fee Schedule																																															
GGT	301	RC	82977	CPT				Both			63	28.35	6.4	56.7	6.4							Fee Schedule		8							Fee Schedule		7.42							Fee Schedule		7.2							Fee Schedule											56.7							Fee Schedule																				7.2							Fee Schedule																				
GI COCKTAIL 30ML UD	250	RC	A9270	CPT				Both			15.75	7.09	0.01	14.18	0.01							Fee Schedule		11.66							Fee Schedule																				7.2							Fee Schedule		14.18							Fee Schedule		8.28							Fee Schedule		6.7							Fee Schedule											8.28							Fee Schedule		6.7							Fee Schedule		
GI SERVICES	750	RC						Both			4200	1890	1890	3780	2730							Fee Schedule		3108							Fee Schedule																													3780							Fee Schedule																																															
GIARDIA ANTIGEN STOOL 8625	306	RC	87328	CPT				Both			120.75	54.34	10.66	108.68	10.66							Fee Schedule		13.82							Fee Schedule		14.23							Fee Schedule		13.82							Fee Schedule											108.68							Fee Schedule																				13.82							Fee Schedule																				
GIGLI SAW BLADE   2808-01	272	RC						Both			72	32.4	12.85	64.8	46.8							Fee Schedule		53.28							Fee Schedule																				13.82							Fee Schedule		64.8							Fee Schedule		15.89							Fee Schedule		12.85							Fee Schedule											15.89							Fee Schedule		12.85							Fee Schedule		
GLASSCOCK DRESSING KIT #S-1000 (SENECA)	272	RC						Both			88	39.6	39.6	79.2	57.2							Fee Schedule		65.12							Fee Schedule																													79.2							Fee Schedule																																															
GLIADIN ANTIBODIES 8889 SERUM	301	RC	83520	CPT				Both			287.7	129.47	12.43	258.93	12.43							Fee Schedule		17.27							Fee Schedule		17.79							Fee Schedule		17.27							Fee Schedule											258.93							Fee Schedule																				17.27							Fee Schedule																				
GLIDE WIRE  630-109	272	RC						Both			215.25	96.86	16.06	193.73	139.91							Fee Schedule		159.29							Fee Schedule																				17.27							Fee Schedule		193.73							Fee Schedule		19.86							Fee Schedule		16.06							Fee Schedule											19.86							Fee Schedule		16.06							Fee Schedule		
GLIDECATH 5FR STRAIGHT TAPER 65CM #CG505	272	RC	C1725	CPT				Both			191	85.95	85.95	171.9	93.3							Fee Schedule		141.34							Fee Schedule																													171.9							Fee Schedule																																															
GLIDECATH 5FR STRAIGHT TAPER 65CM #CG505	272	RC	C1725	CPT				Both			248	111.6	93.3	223.2	93.3							Fee Schedule		183.52							Fee Schedule																													223.2							Fee Schedule																																															
GLIDEPATH HEMODIALYSIS CATH 23CM 5393230	278	RC	C1750	CPT				Both			740.25	333.11	333.11	666.23		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	547.79							Fee Schedule																													666.23							Fee Schedule																																															
GLIDEPATH HEMODIALYSIS CATH 27CM 5393270	278	RC	C1750	CPT				Both			866.25	389.81	389.81	779.63		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	641.03							Fee Schedule																													779.63							Fee Schedule																																															
GLIDESCOPE GVL STAT SIZE 1 #0270-0428	272	RC						Both			83	37.35	37.35	74.7	53.95							Fee Schedule		61.42							Fee Schedule																													74.7							Fee Schedule																																															
GLIDESCOPE GVL STAT SIZE 2 #0270-0429	272	RC						Both			83	37.35	37.35	74.7	53.95							Fee Schedule		61.42							Fee Schedule																													74.7							Fee Schedule																																															
GLIDESCOPE GVL STAT SIZE 3 #0270-0626	272	RC						Both			65	29.25	29.25	58.5	42.25							Fee Schedule		48.1							Fee Schedule																													58.5							Fee Schedule																																															
GLIDESCOPE GVL STAT SIZE 4 #0270-0628	272	RC						Both			65	29.25	29.25	58.5	42.25							Fee Schedule		48.1							Fee Schedule																													58.5							Fee Schedule																																															
GLIDESCOPE STAT #4 0574-0101	272	RC						Both			56.7	25.52	25.52	51.03	36.86							Fee Schedule		41.96							Fee Schedule																													51.03							Fee Schedule																																															
GLIMEPIRIDE 1MG (AMARYL) TABLET	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
GLIMEPIRIDE 2MG (AMARYL) TABLET	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
GLIPIZIDE 10MG (GLUCOTROL) TABLET	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
GLIPIZIDE ER 10MG (GLUCOTROL XL) TABLET	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
GLIPIZIDE ER 5MG (GLUCOTROL XL) TABLET	250	RC	A9270	CPT				Both			6	2.7	0.01	5.4	0.01							Fee Schedule		4.44							Fee Schedule																													5.4							Fee Schedule																																															
GLOVE POW/LATEX FREE 6.5  STERILE (SEN)	272	RC						Both			6.3	2.84	2.84	5.67	4.1							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
GLOVE SINGLE STERILE MED.  MDS194175	272	RC						Both			1.05	0.47	0.47	0.95	0.68							Fee Schedule		0.78							Fee Schedule																													0.95							Fee Schedule																																															
GLU 6 PHOSPHATE 500 1ML EDTA WHOLE BLD	301	RC	82955	CPT				Both			42	18.9	8.62	37.8	8.62							Fee Schedule		10.77							Fee Schedule		9.99							Fee Schedule		9.7							Fee Schedule											37.8							Fee Schedule																				9.7							Fee Schedule																				
GLU TOLERANCE 1 HR NO FASTING	301	RC	82951	CPT				Both			100.8	45.36	9.02	90.72	11.44							Fee Schedule		14.3							Fee Schedule		13.26							Fee Schedule		12.87							Fee Schedule		9.7							Fee Schedule		90.72							Fee Schedule		11.16							Fee Schedule		9.02							Fee Schedule		12.87							Fee Schedule		11.16							Fee Schedule		9.02							Fee Schedule		
GLU TOLERANCE 1 HR WTH FASTING	301	RC	82951	CPT				Both			100.8	45.36	11.44	90.72	11.44							Fee Schedule		14.3							Fee Schedule		13.26							Fee Schedule		12.87							Fee Schedule		12.87							Fee Schedule		90.72							Fee Schedule		14.8							Fee Schedule		11.97							Fee Schedule		12.87							Fee Schedule		14.8							Fee Schedule		11.97							Fee Schedule		
GLUCAGEN 1MG VIAL	636	RC	J1610	CPT				Both			648.9	292.01	11.97	584.01		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	146.33							Fee Schedule		169.81							Fee Schedule		43.54							Fee Schedule		12.87							Fee Schedule		584.01							Fee Schedule		14.8							Fee Schedule		11.97							Fee Schedule											14.8							Fee Schedule		11.97							Fee Schedule		
GLUCAGON 1CC	636	RC	J1610	CPT				Both			76.65	34.49	34.49	189.59		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	146.33							Fee Schedule		169.81							Fee Schedule		43.54							Fee Schedule		164.86							Fee Schedule		68.99							Fee Schedule		189.59							Fee Schedule		153.32							Fee Schedule											189.59							Fee Schedule		153.32							Fee Schedule		
GLUCERNA 1.2 CAL RTH 1000 ML	250	RC	B4154	CPT				Both			63.98	28.79	0.36	189.59	0.36							Fee Schedule		47.35							Fee Schedule											2.21							Fee Schedule		164.86							Fee Schedule		57.58							Fee Schedule		189.59							Fee Schedule		153.32							Fee Schedule											189.59							Fee Schedule		153.32							Fee Schedule		
GLUCERNA 1.2 CAL RTH 237 ML	250	RC	B4154	CPT				Both			7.62	3.43	0.36	6.86	0.36							Fee Schedule		5.64							Fee Schedule											2.21							Fee Schedule											6.86							Fee Schedule																																															
GLUCERNA 1.5 CAL RTH 1000 ML	250	RC	B4154	CPT				Both			79.95	35.98	0.36	71.96	0.36							Fee Schedule		59.16							Fee Schedule											2.21							Fee Schedule											71.96							Fee Schedule																																															
GLUCERNA 240 ML CAN	250	RC						Both			10.5	4.73	4.73	9.45	6.83							Fee Schedule		7.77							Fee Schedule																													9.45							Fee Schedule																																															
GLUCERNA READY TO HANG 1000 ML	250	RC	B4154	CPT				Both			29.4	13.23	0.36	26.46	0.36							Fee Schedule		21.76							Fee Schedule											2.21							Fee Schedule											26.46							Fee Schedule																																															
GLUCOPHAGE XR 500 MG TABLET UD	250	RC	A9270	CPT				Both			4.2	1.89	0.01	3.78	0.01							Fee Schedule		3.11							Fee Schedule																													3.78							Fee Schedule																																															
GLUCOSE	301	RC	82947	CPT				Both			90.3	40.64	3.49	81.27	3.49							Fee Schedule		4.37							Fee Schedule		4.05							Fee Schedule		3.93							Fee Schedule											81.27							Fee Schedule																				3.93							Fee Schedule																				
GLUCOSE 15GM/DOSE ORAL LIQUID TUBE	250	RC	A9270	CPT				Both			12.6	5.67	0.01	11.34	0.01							Fee Schedule		9.32							Fee Schedule																				3.93							Fee Schedule		11.34							Fee Schedule		4.52							Fee Schedule		3.65							Fee Schedule											4.52							Fee Schedule		3.65							Fee Schedule		
GLUCOSE 5GM/DOSE ORAL LIQUID TUBE	250	RC	A9270	CPT				Both			7.76	3.49	0.01	6.98	0.01							Fee Schedule		5.74							Fee Schedule																													6.98							Fee Schedule																																															
GLUCOSE BLOOD STICK (MONITOR ONLY)	300	RC	82948	CPT				Both			21	9.45	3.63	18.9	3.63							Fee Schedule		5.04							Fee Schedule		5.19							Fee Schedule		5.04							Fee Schedule											18.9							Fee Schedule																				5.04							Fee Schedule																				
GLUCOSE CSF	301	RC	82947	CPT				Both			52.5	23.63	3.49	47.25	3.49							Fee Schedule		4.37							Fee Schedule		4.05							Fee Schedule		3.93							Fee Schedule		5.04							Fee Schedule		47.25							Fee Schedule		5.8							Fee Schedule		4.69							Fee Schedule		3.93							Fee Schedule		5.8							Fee Schedule		4.69							Fee Schedule		
GLUCOSE FLUID 1ML FLUID	301	RC	82945	CPT				Both			52.5	23.63	3.49	47.25	3.49							Fee Schedule		4.37							Fee Schedule		4.05							Fee Schedule		3.93							Fee Schedule		3.93							Fee Schedule		47.25							Fee Schedule		4.52							Fee Schedule		3.65							Fee Schedule		3.93							Fee Schedule		4.52							Fee Schedule		3.65							Fee Schedule		
GLUCOSE SOFT TABS-4GM TABS	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																				3.93							Fee Schedule		5.67							Fee Schedule		4.52							Fee Schedule		3.65							Fee Schedule											4.52							Fee Schedule		3.65							Fee Schedule		
GLUCOSE TOLERANCE EACH ADDL:  SPEC	301	RC	82952	CPT				Both			52.5	23.63	3.48	47.25	3.48							Fee Schedule		4.36							Fee Schedule		4.04							Fee Schedule		3.92							Fee Schedule											47.25							Fee Schedule																				3.92							Fee Schedule																				
GLUCOSE URINE	301	RC	82947	CPT				Both			52.5	23.63	3.49	47.25	3.49							Fee Schedule		4.37							Fee Schedule		4.05							Fee Schedule		3.93							Fee Schedule		3.92							Fee Schedule		47.25							Fee Schedule		4.51							Fee Schedule		3.65							Fee Schedule		3.93							Fee Schedule		4.51							Fee Schedule		3.65							Fee Schedule		
GLUCOTROL 5 MG (GLIPIZIDE)	250	RC	A9270	CPT				Both			4.2	1.89	0.01	4.52	0.01							Fee Schedule		3.11							Fee Schedule																				3.93							Fee Schedule		3.78							Fee Schedule		4.52							Fee Schedule		3.65							Fee Schedule											4.52							Fee Schedule		3.65							Fee Schedule		
GLUCOTROL XL 5 MG TABLET UD	250	RC	A9270	CPT				Both			4.2	1.89	0.01	3.78	0.01							Fee Schedule		3.11							Fee Schedule																													3.78							Fee Schedule																																															
GLUCOVANCE 2.5 MG/500 MG.	250	RC	A9270	CPT				Both			4.2	1.89	0.01	3.78	0.01							Fee Schedule		3.11							Fee Schedule																													3.78							Fee Schedule																																															
GLUCOVANCE 5 MG/500 MG.	250	RC	A9270	CPT				Both			4.2	1.89	0.01	3.78	0.01							Fee Schedule		3.11							Fee Schedule																													3.78							Fee Schedule																																															
GLUTAMINE 15 GM PKTS (SYMPT-X G.I.)	250	RC						Both			10.8	4.86	4.86	9.72	7.02							Fee Schedule		7.99							Fee Schedule																													9.72							Fee Schedule																																															
GLUTAMINE PLUS POWDER	250	RC	A9270	CPT				Both			4.2	1.89	0.01	3.78	0.01							Fee Schedule		3.11							Fee Schedule																													3.78							Fee Schedule																																															
"GLUTATHIONE, TOTAL WB 38813"	301	RC	82978	CPT				Both			54.6	24.57	12.67	49.14	12.67							Fee Schedule		15.84							Fee Schedule		15.91							Fee Schedule		15.45							Fee Schedule											49.14							Fee Schedule																				15.45							Fee Schedule																				
GLYBURIDE 2.5MG (DIABETA) TABLET	250	RC	A9270	CPT				Both			6.3	2.84	0.01	17.77	0.01							Fee Schedule		4.66							Fee Schedule																				15.45							Fee Schedule		5.67							Fee Schedule		17.77							Fee Schedule		14.37							Fee Schedule											17.77							Fee Schedule		14.37							Fee Schedule		
GLYBURIDE 5MG (DIABETA) TABLET	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
GLYCERIN EMOL 6OZ	250	RC						Both			17.48	7.87	7.87	15.73	11.36							Fee Schedule		12.94							Fee Schedule																													15.73							Fee Schedule																																															
GLYCERIN INFANT SUPP	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
GLYCERIN RECTAL SUPPOSITORY- ADULT	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
GLYCOPYRROLATE 0.2 MG/ML 20ML INJECTION	250	RC	J1596	CPT				Both			26.79	12.06	0.38	24.11	17.41							Fee Schedule		19.82							Fee Schedule		0.38							Fee Schedule																				24.11							Fee Schedule																																															
GLYCOPYRROLATE 0.2 MG/ML-1ML SDV	250	RC	J1596	CPT				Both			10.17	4.58	0.34	9.15	6.61							Fee Schedule		7.53							Fee Schedule		0.38							Fee Schedule											0.37							Fee Schedule		9.15							Fee Schedule		0.42							Fee Schedule		0.34							Fee Schedule											0.42							Fee Schedule		0.34							Fee Schedule		
GLYNASE 3 MG TABLET U/D	250	RC	A9270	CPT				Both			5.25	2.36	0.01	4.73	0.01							Fee Schedule		3.89							Fee Schedule																				0.37							Fee Schedule		4.73							Fee Schedule		0.42							Fee Schedule		0.34							Fee Schedule											0.42							Fee Schedule		0.34							Fee Schedule		
GOLD BOND MEDICATED POWDER	250	RC	A9270	CPT				Both			9.14	4.11	0.01	8.23	0.01							Fee Schedule		6.76							Fee Schedule																													8.23							Fee Schedule																																															
GOLD BOND POWDER	250	RC	A9270	CPT				Both			9.01	4.05	0.01	8.11	0.01							Fee Schedule		6.67							Fee Schedule																													8.11							Fee Schedule																																															
GOLYTELY	250	RC	A9270	CPT				Both			75.6	34.02	0.01	68.04	0.01							Fee Schedule		55.94							Fee Schedule																													68.04							Fee Schedule																																															
GOODE-T-TUBE EAR TUBE NEW# 240071	272	RC						Both			66	29.7	29.7	59.4	42.9							Fee Schedule		48.84							Fee Schedule																													59.4							Fee Schedule																																															
GORE BALLOON CATHETER #MOB37	272	RC	C1725	CPT				Both			1685.25	758.36	93.3	1516.73	93.3							Fee Schedule		1247.09							Fee Schedule																													1516.73							Fee Schedule																																															
GORE DRYSEAL INTRODUCER SHEATH #DSF1233	272	RC	C1894	CPT				Both			1515.15	681.82	87.34	1363.64	87.34							Fee Schedule		1121.21							Fee Schedule																													1363.64							Fee Schedule																																															
GORE DRYSEAL INTRODUCER SHEATH #DSF1633	272	RC	C1894	CPT				Both			1515.15	681.82	87.34	1363.64	87.34							Fee Schedule		1121.21							Fee Schedule																													1363.64							Fee Schedule																																															
GORE EXCLUDER ENDOPROSTHESIS #PLC181000	278	RC						Both			15680.7	7056.32	7056.32	14112.63		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	11603.72							Fee Schedule																													14112.63							Fee Schedule																																															
GORE EXCLUDER ENDOPROSTHESIS #RLT261416	278	RC						Both			38247.3	17211.29	17211.29	34422.57		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	28303							Fee Schedule																													34422.57							Fee Schedule																																															
GORE VIABAHN BALLOON CATH  BXA077902A	278	RC	C1874	CPT				Both			11763	5293.35	5293.35	10586.7		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	8704.62							Fee Schedule																													10586.7							Fee Schedule																																															
GORE VIABAHN BALLOON CATH 7F  BXA085902A	278	RC	C1874	CPT				Both			11258.1	5066.15	5066.15	10132.29		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	8330.99							Fee Schedule																													10132.29							Fee Schedule																																															
GORE VIABAHN BALLOON CATH 8F  BXA087902A	278	RC	C1874	CPT				Both			11812.5	5315.63	5315.63	10631.25		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	8741.25							Fee Schedule																													10631.25							Fee Schedule																																															
GORE VIABAHN BALLOON CATH 8F  BXA097902A	272	RC	C1874	CPT				Both			12351.15	5558.02	315.17	11116.04	315.17							Fee Schedule		9139.85							Fee Schedule																													11116.04							Fee Schedule																																															
GORE VIABAHN BALLOON CATH 8F  BXA107902A	272	RC	C1874	CPT				Both			12351.15	5558.02	315.17	11116.04	315.17							Fee Schedule		9139.85							Fee Schedule																													11116.04							Fee Schedule																																															
GORE VIABAHN SX ENDO  VBHR070502A	278	RC	C1874	CPT				Both			11769	5296.05	5296.05	10592.1		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	8709.06							Fee Schedule																													10592.1							Fee Schedule																																															
GORE VIABAHN SX ENDO  VBHR070702A	278	RC	C1874	CPT				Both			11769	5296.05	5296.05	10592.1		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	8709.06							Fee Schedule																													10592.1							Fee Schedule																																															
GORE VIABAHN SX ENDO 7FR.  VBHR060502A	278	RC	C1874	CPT				Both			10773	4847.85	4847.85	9695.7		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	7972.02							Fee Schedule																													9695.7							Fee Schedule																																															
GORE VIABANN CATH 6FR VBJR060502A	272	RC	C1874	CPT				Both			11374.65	5118.59	315.17	10237.19	315.17							Fee Schedule		8417.24							Fee Schedule																													10237.19							Fee Schedule																																															
GORE VIABANN CATH 6FR VBJR080202A	272	RC	C1874	CPT				Both			11374.65	5118.59	315.17	10237.19	315.17							Fee Schedule		8417.24							Fee Schedule																													10237.19							Fee Schedule																																															
GORETEX MESH 2.5 X7   #1DLMC05	278	RC	C1781	CPT				Both			822.15	369.97	369.97	739.94		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	608.39							Fee Schedule																													739.94							Fee Schedule																																															
GORTEX CAST LINING	271	RC						Both			2.1	0.95	0.95	1.89	1.37							Fee Schedule		1.55							Fee Schedule																													1.89							Fee Schedule																																															
GORTEX DUAL MESH BIOMATERIAL (884 SQ.CM)	278	RC	C1781	CPT				Both			6559.35	2951.71	2951.71	5903.42		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	4853.92							Fee Schedule																													5903.42							Fee Schedule																																															
GORTEX STAN.VASC.WALL GRAFT #RR08020030L	278	RC	C1781	CPT				Both			2069.55	931.3	931.3	1862.6		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1531.47							Fee Schedule																													1862.6							Fee Schedule																																															
GOWN PREVENTION LG DYNJP2207S	270	RC						Both			9	4.05	4.05	8.1	5.85							Fee Schedule		6.66							Fee Schedule																													8.1							Fee Schedule																																															
GOWN STERILE 3XL DYNJP2004	272	RC						Both			13	5.85	5.85	11.7	8.45							Fee Schedule		9.62							Fee Schedule																													11.7							Fee Schedule																																															
GOWNS ISOLATION THUMBS UP #NONTH200	270	RC						Both			2.1	0.95	0.95	1.89	1.37							Fee Schedule		1.55							Fee Schedule																													1.89							Fee Schedule																																															
GOWNS STERILE LG  DYNJP2701/ DYNJP2001S	270	RC						Both			6	2.7	2.7	5.4	3.9							Fee Schedule		4.44							Fee Schedule																													5.4							Fee Schedule																																															
GRAFIX PL PRIME SKIN SUB 1.5X2CM PS13015	636	RC	Q4133	CPT				Both			645	290.25	130.95	580.5		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	477.3							Fee Schedule		130.95							Fee Schedule																				580.5							Fee Schedule																																															
GRAFIX PL PRIME SKIN SUB 16MM PS13016	278	RC	Q4133	CPT				Both			585	263.25	118.24	526.5		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	432.9							Fee Schedule		130.95							Fee Schedule											127.14							Fee Schedule		526.5							Fee Schedule		146.21							Fee Schedule		118.24							Fee Schedule											146.21							Fee Schedule		118.24							Fee Schedule		
GRAFIX PL PRIME SKIN SUB 2X3CM PS13023	278	RC	Q4133	CPT				Both			495	222.75	118.24	445.5		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	366.3							Fee Schedule		130.95							Fee Schedule											127.14							Fee Schedule		445.5							Fee Schedule		146.21							Fee Schedule		118.24							Fee Schedule											146.21							Fee Schedule		118.24							Fee Schedule		
GRAFIX PL PRIME SKIN SUB 3X3CM PS13033	278	RC	Q4133	CPT				Both			396	178.2	118.24	356.4		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	293.04							Fee Schedule		130.95							Fee Schedule											127.14							Fee Schedule		356.4							Fee Schedule		146.21							Fee Schedule		118.24							Fee Schedule											146.21							Fee Schedule		118.24							Fee Schedule		
GRAFIX PL PRIME SKIN SUB 3X4CM PS13034	278	RC	Q4133	CPT				Both			321	144.45	118.24	288.9		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	237.54							Fee Schedule		130.95							Fee Schedule											127.14							Fee Schedule		288.9							Fee Schedule		146.21							Fee Schedule		118.24							Fee Schedule											146.21							Fee Schedule		118.24							Fee Schedule		
GRAFT BARD DEBAKEY	278	RC	L8670	CPT				Both			1348.2	606.69	118.24	1213.38		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	997.67							Fee Schedule		701.93							Fee Schedule											127.14							Fee Schedule		1213.38							Fee Schedule		146.21							Fee Schedule		118.24							Fee Schedule											146.21							Fee Schedule		118.24							Fee Schedule		
GRAFT DEBAKEY BIFURCATED	278	RC	L8670	CPT				Both			1348.2	606.69	606.69	1213.38		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	997.67							Fee Schedule		701.93							Fee Schedule											681.49							Fee Schedule		1213.38							Fee Schedule		783.71							Fee Schedule		633.79							Fee Schedule											783.71							Fee Schedule		633.79							Fee Schedule		
GRAFT FLEX 6X70 #F7006 (BARD VASCULAR)	278	RC	L8670	CPT				Both			3482.85	1567.28	633.79	3134.57		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	2577.31							Fee Schedule		701.93							Fee Schedule											681.49							Fee Schedule		3134.57							Fee Schedule		783.71							Fee Schedule		633.79							Fee Schedule											783.71							Fee Schedule		633.79							Fee Schedule		
GRAFT IMPRA FELT #007837 (BARD VASCULAR)	278	RC	L8670	CPT				Both			633.15	284.92	284.92	783.71		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	468.53							Fee Schedule		701.93							Fee Schedule											681.49							Fee Schedule		569.84							Fee Schedule		783.71							Fee Schedule		633.79							Fee Schedule											783.71							Fee Schedule		633.79							Fee Schedule		
GRAFT IMPRA PTFE 6MMX70CM (BARD VASCULAR	278	RC	L8670	CPT				Both			2056.95	925.63	633.79	1851.26		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1522.14							Fee Schedule		701.93							Fee Schedule											681.49							Fee Schedule		1851.26							Fee Schedule		783.71							Fee Schedule		633.79							Fee Schedule											783.71							Fee Schedule		633.79							Fee Schedule		
GRAFT IMPRA PTFE 8MMX70CM (BARD VASCULAR	278	RC	L8670	CPT				Both			2915.85	1312.13	633.79	2624.27		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	2157.73							Fee Schedule		701.93							Fee Schedule											681.49							Fee Schedule		2624.27							Fee Schedule		783.71							Fee Schedule		633.79							Fee Schedule											783.71							Fee Schedule		633.79							Fee Schedule		
GRAFT PTFE 8X70 #70S08 (BARD VASCULAR)	278	RC	L8670	CPT				Both			2471.7	1112.27	633.79	2224.53		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1829.06							Fee Schedule		701.93							Fee Schedule											681.49							Fee Schedule		2224.53							Fee Schedule		783.71							Fee Schedule		633.79							Fee Schedule											783.71							Fee Schedule		633.79							Fee Schedule		
GRAFT VASCULAR FUSION BIOLINE 6MMX40CM	278	RC	L8670	CPT				Both			4252.5	1913.63	633.79	3827.25		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	3146.85							Fee Schedule		701.93							Fee Schedule											681.49							Fee Schedule		3827.25							Fee Schedule		783.71							Fee Schedule		633.79							Fee Schedule											783.71							Fee Schedule		633.79							Fee Schedule		
GRAFT VASCULAR VELOUR M002020851260	278	RC	L8670	CPT				Both			2127	957.15	633.79	1914.3		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1573.98							Fee Schedule		701.93							Fee Schedule											681.49							Fee Schedule		1914.3							Fee Schedule		783.71							Fee Schedule		633.79							Fee Schedule											783.71							Fee Schedule		633.79							Fee Schedule		
GRAFT VASCULAR VELOUR M002020851470	278	RC	L8670	CPT				Both			2127	957.15	633.79	1914.3		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1573.98							Fee Schedule		701.93							Fee Schedule											681.49							Fee Schedule		1914.3							Fee Schedule		783.71							Fee Schedule		633.79							Fee Schedule											783.71							Fee Schedule		633.79							Fee Schedule		
GRAFT VASCULAR VELOUR M002020851470	278	RC	L8670	CPT				Both			2127	957.15	633.79	1914.3		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1573.98							Fee Schedule		701.93							Fee Schedule											681.49							Fee Schedule		1914.3							Fee Schedule		783.71							Fee Schedule		633.79							Fee Schedule											783.71							Fee Schedule		633.79							Fee Schedule		
GRAFTON LIQUID BONE GRAFT 1CC	278	RC	C9359	CPT				Both			452.55	203.65	203.65	783.71		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	334.89							Fee Schedule																				681.49							Fee Schedule		407.3							Fee Schedule		783.71							Fee Schedule		633.79							Fee Schedule											783.71							Fee Schedule		633.79							Fee Schedule		
GRAM STAIN	306	RC	87205	CPT				Both			45.15	20.32	3.79	40.64	3.79							Fee Schedule		4.75							Fee Schedule		4.4							Fee Schedule		4.27							Fee Schedule											40.64							Fee Schedule																				4.27							Fee Schedule																				
GRAM STAIN SPUTUM	306	RC	87205	CPT				Both			45.15	20.32	3.79	40.64	3.79							Fee Schedule		4.75							Fee Schedule		4.4							Fee Schedule		4.27							Fee Schedule		4.27							Fee Schedule		40.64							Fee Schedule		4.91							Fee Schedule		3.97							Fee Schedule		4.27							Fee Schedule		4.91							Fee Schedule		3.97							Fee Schedule		
GRANISETRON 0.1MG/ML (KYTRIL) INJ	636	RC	J1626	CPT				Both			12.6	5.67	0.2	22.81		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	9.32							Fee Schedule		0.2							Fee Schedule		22.81							Fee Schedule		4.27							Fee Schedule		11.34							Fee Schedule		4.91							Fee Schedule		3.97							Fee Schedule											4.91							Fee Schedule		3.97							Fee Schedule		
GRANISETRON 1MG (KYTRIL) TABLET	636	RC	Q0166	CPT				Both			185.66	83.55	0.19	167.09		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	137.39							Fee Schedule																				0.2							Fee Schedule		167.09							Fee Schedule		0.23							Fee Schedule		0.19							Fee Schedule											0.23							Fee Schedule		0.19							Fee Schedule		
GRANULEX SPRAY- 60 GM	250	RC	A9270	CPT				Both			47.72	21.47	0.01	42.95	0.01							Fee Schedule		35.31							Fee Schedule																													42.95							Fee Schedule																																															
GRASP FORCEPS FLEXCYSTO FG-253SX	272	RC						Both			223	100.35	100.35	200.7	144.95							Fee Schedule		165.02							Fee Schedule																													200.7							Fee Schedule																																															
GRASPING FORCEP ALLIGATOR  DGC-383-5	272	RC						Both			267.75	120.49	120.49	240.98	174.04							Fee Schedule		198.14							Fee Schedule																													240.98							Fee Schedule																																															
GRIPPER NEEDLE 19X1  SAFETY #21-2969-24	272	RC						Both			14	6.3	6.3	12.6	9.1							Fee Schedule		10.36							Fee Schedule																													12.6							Fee Schedule																																															
GRIPPER NEEDLE 20X1  SAFETY #21-2966-24	272	RC						Both			14	6.3	6.3	12.6	9.1							Fee Schedule		10.36							Fee Schedule																													12.6							Fee Schedule																																															
GRIPPER NEEDLE 20X1 1/4 SAFE #21-2967-24	272	RC						Both			14	6.3	6.3	12.6	9.1							Fee Schedule		10.36							Fee Schedule																													12.6							Fee Schedule																																															
GRIPPER NEEDLE 22X.75 SAFETY #21-2961-24	272	RC						Both			16	7.2	7.2	14.4	10.4							Fee Schedule		11.84							Fee Schedule																													14.4							Fee Schedule																																															
GRIPPER NEEDLE 22X1  SAFETY #21-2962-24	272	RC						Both			15	6.75	6.75	13.5	9.75							Fee Schedule		11.1							Fee Schedule																													13.5							Fee Schedule																																															
GROUNDING/BOVIE PAD (DEROYAL)	272	RC						Both			17.85	8.03	8.03	16.07	11.6							Fee Schedule		13.21							Fee Schedule																													16.07							Fee Schedule																																															
GROUP & TYPE	300	RC	86900	CPT				Both			100.8	45.36	2.66	90.72	2.66							Fee Schedule		3.32							Fee Schedule		3.08							Fee Schedule		2.99							Fee Schedule											90.72							Fee Schedule																				2.99							Fee Schedule																				
GUAIFENESIN 200 MG/10ML SYRUP UD	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																				2.99							Fee Schedule		5.67							Fee Schedule		3.44							Fee Schedule		2.78							Fee Schedule											3.44							Fee Schedule		2.78							Fee Schedule		
GUAIFENESIN 200MG/CODEINE 20MG/10ML SYRU	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
GUAIFENESIN 300 MG/15ML SYRUP UD	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
GUAIFENESIN DM 200/20 MG-10ML SYRUP UD	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
GUAIFENESIN ER 600MG TABLET (MUCINEX)	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
GUAIFENESIN/PSE 600-120MG TABLET	250	RC	A9270	CPT				Both			5.25	2.36	0.01	4.73	0.01							Fee Schedule		3.89							Fee Schedule																													4.73							Fee Schedule																																															
GUANFACINE 1MG (TENEX) TABLET	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
GUEDEL AIRWAY 100MM 3500EU	271	RC						Both			1.05	0.47	0.47	0.95	0.68							Fee Schedule		0.78							Fee Schedule																													0.95							Fee Schedule																																															
GUEDEL AIRWAY 60MM	271	RC						Both			4.2	1.89	1.89	3.78	2.73							Fee Schedule		3.11							Fee Schedule																													3.78							Fee Schedule																																															
GUEDEL AIRWAY 70M 3570/3570EU	271	RC						Both			2.1	0.95	0.95	1.89	1.37							Fee Schedule		1.55							Fee Schedule																													1.89							Fee Schedule																																															
GUEDEL AIRWAY 80MM  3580EU	271	RC						Both			2.1	0.95	0.95	1.89	1.37							Fee Schedule		1.55							Fee Schedule																													1.89							Fee Schedule																																															
GUEDEL AIRWAY 9.0 CM 3590	271	RC						Both			1.05	0.47	0.47	0.95	0.68							Fee Schedule		0.78							Fee Schedule																													0.95							Fee Schedule																																															
GUIDE WIRE GW35061	272	RC	C1769	CPT				Both			253.05	113.87	113.87	227.75	154.26							Fee Schedule		187.26							Fee Schedule																													227.75							Fee Schedule																																															
GUIDEWIRE 2700MMX0.025 G-240-2527S	272	RC	C1769	CPT				Both			484.05	217.82	154.26	435.65	154.26							Fee Schedule		358.2							Fee Schedule																													435.65							Fee Schedule																																															
GUIDEWIRE NITINOL WITH STR. TIP #670305	272	RC	C1769	CPT				Both			131.25	59.06	59.06	154.26	154.26							Fee Schedule		97.13							Fee Schedule																													118.13							Fee Schedule																																															
GYNE-LOTRIMIN TAB	250	RC	A9270	CPT				Both			50.27	22.62	0.01	45.24	0.01							Fee Schedule		37.2							Fee Schedule																													45.24							Fee Schedule																																															
GYNEX BALL LOOP 2-5-2	272	RC						Both			37.8	17.01	17.01	34.02	24.57							Fee Schedule		27.97							Fee Schedule																													34.02							Fee Schedule																																															
GYNEX BALL LOOP 3MM #2-3-2	272	RC						Both			39.9	17.96	17.96	35.91	25.94							Fee Schedule		29.53							Fee Schedule																													35.91							Fee Schedule																																															
GYNEX LLETZ ELECTRODE 15-0001	272	RC						Both			36	16.2	16.2	32.4	23.4							Fee Schedule		26.64							Fee Schedule																													32.4							Fee Schedule																																															
GYNEX LOOP 12-05-05	272	RC						Both			39.9	17.96	17.96	35.91	25.94							Fee Schedule		29.53							Fee Schedule																													35.91							Fee Schedule																																															
GYNEX LOOP 12-15-12	272	RC						Both			39.9	17.96	17.96	35.91	25.94							Fee Schedule		29.53							Fee Schedule																													35.91							Fee Schedule																																															
GYNEX LOOP 12-20-10	272	RC						Both			39.9	17.96	17.96	35.91	25.94							Fee Schedule		29.53							Fee Schedule																													35.91							Fee Schedule																																															
GYNEX LOOP 12-20-13	272	RC						Both			39.9	17.96	17.96	35.91	25.94							Fee Schedule		29.53							Fee Schedule																													35.91							Fee Schedule																																															
GYNEX LOOP ELECTR.# 12-1007	272	RC						Both			45	20.25	20.25	40.5	29.25							Fee Schedule		33.3							Fee Schedule																													40.5							Fee Schedule																																															
GYNEX LOOP ELECTR.# 12-2015	272	RC						Both			38	17.1	17.1	34.2	24.7							Fee Schedule		28.12							Fee Schedule																													34.2							Fee Schedule																																															
GYNEX LOOP ELECTR.# 12-2515  25MMX15MM	272	RC						Both			43	19.35	19.35	38.7	27.95							Fee Schedule		31.82							Fee Schedule																													38.7							Fee Schedule																																															
GYRUS CUTTING FORCEP #920005PK	272	RC						Both			1264.2	568.89	568.89	1137.78	821.73							Fee Schedule		935.51							Fee Schedule																													1137.78							Fee Schedule																																															
GYRUS D&E CANISTER 003987-901 (OLYMPUS)	271	RC						Both			26.25	11.81	11.81	23.63	17.06							Fee Schedule		19.43							Fee Schedule																													23.63							Fee Schedule																																															
GYRUS DISSECTING FORCEP #942005PK	272	RC						Both			618.45	278.3	278.3	556.61	401.99							Fee Schedule		457.65							Fee Schedule																													556.61							Fee Schedule																																															
GYRUS HOUSE WIRE LOOP #140186	272	RC						Both			174.3	78.44	78.44	156.87	113.3							Fee Schedule		128.98							Fee Schedule																													156.87							Fee Schedule																																															
GYRUS PAPARELLA VENT EAR TUBE #240044	278	RC						Both			39.9	17.96	17.96	35.91		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	29.53							Fee Schedule																													35.91							Fee Schedule																																															
GYRUS PLASMA TRISSECTOR #940010PC	272	RC						Both			1460.55	657.25	657.25	1314.5	949.36							Fee Schedule		1080.81							Fee Schedule																													1314.5							Fee Schedule																																															
GYRUS SCHUKNECHT CRESCENT #140219	278	RC						Both			174.3	78.44	78.44	156.87		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	128.98							Fee Schedule																													156.87							Fee Schedule																																															
GYRUS STRAIGHT EAR TUBE #145007	272	RC						Both			17.85	8.03	8.03	16.07	11.6							Fee Schedule		13.21							Fee Schedule																													16.07							Fee Schedule																																															
GYRUS TAPWIRE PIPE #140185	272	RC						Both			154.35	69.46	69.46	138.92	100.33							Fee Schedule		114.22							Fee Schedule																													138.92							Fee Schedule																																															
"H PYLORI, UREA BREATH TEST 14839"	302	RC	83013	CPT				Both			480	216	59.88	432	59.88							Fee Schedule		74.84							Fee Schedule		69.38							Fee Schedule		67.36							Fee Schedule											432							Fee Schedule																																															
H UTERINE INJECTOR	272	RC						Both			61.95	27.88	27.88	77.46	40.27							Fee Schedule		45.84							Fee Schedule																				67.36							Fee Schedule		55.76							Fee Schedule		77.46							Fee Schedule		62.64							Fee Schedule											77.46							Fee Schedule		62.64							Fee Schedule		
HAEMOPHILUS INFLU AB IGG 35135 1ML SERUM	302	RC	86403	CPT				Both			101.85	45.83	9.06	91.67	9.06							Fee Schedule		11.54							Fee Schedule		11.89							Fee Schedule		11.54							Fee Schedule											91.67							Fee Schedule																				11.54							Fee Schedule																				
HALCION 0.25 MG TABLETS	250	RC	A9270	CPT				Both			4.2	1.89	0.01	13.27	0.01							Fee Schedule		3.11							Fee Schedule																				11.54							Fee Schedule		3.78							Fee Schedule		13.27							Fee Schedule		10.73							Fee Schedule											13.27							Fee Schedule		10.73							Fee Schedule		
HALDOL 564 SERUM	301	RC	80173	CPT				Both			129.15	58.12	12.95	116.24	12.95							Fee Schedule		16.18							Fee Schedule		16.25							Fee Schedule		15.78							Fee Schedule											116.24							Fee Schedule																				15.78							Fee Schedule																				
HALDOL DECANOATE 50 MG/ML-1ML	636	RC	J1631	CPT				Both			181.06	81.48	5.45	162.95		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	133.98							Fee Schedule		5.45							Fee Schedule		37.02							Fee Schedule		15.78							Fee Schedule		162.95							Fee Schedule		18.15							Fee Schedule		14.68							Fee Schedule											18.15							Fee Schedule		14.68							Fee Schedule		
HALDOL DECANOATE 50MG INJECTION	636	RC	J1631	CPT				Both			108.32	48.74	4.92	97.49		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	80.16							Fee Schedule		5.45							Fee Schedule		37.02							Fee Schedule		5.29							Fee Schedule		97.49							Fee Schedule		6.08							Fee Schedule		4.92							Fee Schedule											6.08							Fee Schedule		4.92							Fee Schedule		
HALEYS MO (PER OZ)	250	RC	A9270	CPT				Both			4.2	1.89	0.01	6.08	0.01							Fee Schedule		3.11							Fee Schedule																				5.29							Fee Schedule		3.78							Fee Schedule		6.08							Fee Schedule		4.92							Fee Schedule											6.08							Fee Schedule		4.92							Fee Schedule		
HALF APRON STA DRI AH700 (SENECA)	271	RC						Both			5	2.25	2.25	4.5	3.25							Fee Schedule		3.7							Fee Schedule																													4.5							Fee Schedule																																															
HALFPRIN 162 MG TABS	250	RC	A9270	CPT				Both			5.25	2.36	0.01	4.73	0.01							Fee Schedule		3.89							Fee Schedule																													4.73							Fee Schedule																																															
HALOPERIDOL  2 MG/ML ORAL SOLUTION-120ML	250	RC	A9270	CPT				Both			100.4	45.18	0.01	90.36	0.01							Fee Schedule		74.3							Fee Schedule																													90.36							Fee Schedule																																															
HALOPERIDOL  5 MG/ML-1ML (HALDOL) INJ	636	RC	J1630	CPT				Both			12.6	5.67	0.77	11.34		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	9.32							Fee Schedule		0.77							Fee Schedule		2.35							Fee Schedule											11.34							Fee Schedule																																															
HALOPERIDOL 1MG (HALDOL) TABLET	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																				0.75							Fee Schedule		5.67							Fee Schedule		0.86							Fee Schedule		0.69							Fee Schedule											0.86							Fee Schedule		0.69							Fee Schedule		
HALOPERIDOL 5MG (HALDOL) TABLET	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
HAMILTON MED. BREATHING CIRCUIT 260161	270	RC	A4618	CPT				Both			112	50.4	4.33	100.8	6.81							Fee Schedule		82.88							Fee Schedule		11.1							Fee Schedule		4.33							Fee Schedule											100.8							Fee Schedule																																															
HAMILTON MED. VENT HEPA FILTER 201022	270	RC						Both			7	3.15	3.15	12.4	4.55							Fee Schedule		5.18							Fee Schedule																				10.78							Fee Schedule		6.3							Fee Schedule		12.4							Fee Schedule		10.03							Fee Schedule											12.4							Fee Schedule		10.03							Fee Schedule		
HAND EXERCISER ( SAMMONS PRESTON )	270	RC						Both			16.8	7.56	7.56	15.12	10.92							Fee Schedule		12.43							Fee Schedule																													15.12							Fee Schedule																																															
HAND LT	320	RC	73130	CPT				Both			315	141.75	15.33	318	18.8							Fee Schedule		22.27							Fee Schedule											15.33							Fee Schedule											283.5							Fee Schedule																				318							Per Diem																				
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH MCC					356	DRG		Inpatient			52823.05	23770.37	23770.37	23770.37							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period	
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH CC					357	DRG		Inpatient			108372.25	48767.51	48767.51	48767.51							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period				6580.37	6580.37	6580.37	1 through 10									0		No services provided during 15 month lookback							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period	
HAND PUTTY	271	RC						Both			10.5	4.73	4.73	9.45	6.83							Fee Schedule		7.77							Fee Schedule																													9.45							Fee Schedule																																															
HAND RT	320	RC	73130	CPT				Both			315	141.75	15.33	318	18.8							Fee Schedule		22.27							Fee Schedule											15.33							Fee Schedule											283.5							Fee Schedule																				318							Per Diem																				
HANDPIECE SET W/ HIGH FLOW #0210-114-100	272	RC						Both			125	56.25	56.25	112.5	81.25							Fee Schedule		92.5							Fee Schedule																													112.5							Fee Schedule																																															
HANDPIECE TUBING	272	RC						Both			135.45	60.95	60.95	121.91	88.04							Fee Schedule		100.23							Fee Schedule																													121.91							Fee Schedule																																															
HANDTROL CONMED #60-0300-501 NEW#130309A	272	RC						Both			8.4	3.78	3.78	7.56	5.46							Fee Schedule		6.22							Fee Schedule																													7.56							Fee Schedule																																															
HAPAD METATARSAL ARCH PAD	274	RC	L3410	CPT				Both			18.9	8.51	8.51	118.18		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	13.99							Fee Schedule		118.18							Fee Schedule																				17.01							Fee Schedule																																															
HAPTOGLOBIN 502 SERUM	301	RC	83010	CPT				Both			262.5	118.13	11.18	236.25	11.18							Fee Schedule		13.97							Fee Schedule		12.96							Fee Schedule		12.58							Fee Schedule		114.74							Fee Schedule		236.25							Fee Schedule		131.95							Fee Schedule		106.71							Fee Schedule		12.58							Fee Schedule		131.95							Fee Schedule		106.71							Fee Schedule		
HARMONIC SCALPEL #HP052	272	RC						Both			6291.6	2831.22	11.7	5662.44	4089.54							Fee Schedule		4655.78							Fee Schedule																				12.58							Fee Schedule		5662.44							Fee Schedule		14.47							Fee Schedule		11.7							Fee Schedule											14.47							Fee Schedule		11.7							Fee Schedule		
HARMONIC SCALPEL 5MM ADAPTOR HSAO6	272	RC						Both			152.25	68.51	68.51	137.03	98.96							Fee Schedule		112.67							Fee Schedule																													137.03							Fee Schedule																																															
HARMONIC SCALPEL 5MM HD SHEATH HDH05	272	RC						Both			584.85	263.18	263.18	526.37	380.15							Fee Schedule		432.79							Fee Schedule																													526.37							Fee Schedule																																															
HARMONIC SCALPEL ADAPTOR ADP15	272	RC						Both			152.25	68.51	68.51	137.03	98.96							Fee Schedule		112.67							Fee Schedule																													137.03							Fee Schedule																																															
HARMONIC SCALPEL COAG SHEARS 15MM CS150	272	RC						Both			1150.8	517.86	517.86	1035.72	748.02							Fee Schedule		851.59							Fee Schedule																													1035.72							Fee Schedule																																															
HARMONIC SCALPEL CURVED BLADE 32CM HC325	272	RC						Both			584.85	263.18	263.18	526.37	380.15							Fee Schedule		432.79							Fee Schedule																													526.37							Fee Schedule																																															
HARMONIC SCALPEL CURVED BLADE10CM HC105	272	RC						Both			495.6	223.02	223.02	446.04	322.14							Fee Schedule		366.74							Fee Schedule																													446.04							Fee Schedule																																															
HARMONIC SCALPEL CURVED SHEAR LCSC5	272	RC						Both			1348.2	606.69	606.69	1213.38	876.33							Fee Schedule		997.67							Fee Schedule																													1213.38							Fee Schedule																																															
HARMONIC SCALPEL DISECT HOOK 10CM DH105	272	RC						Both			354.9	159.71	159.71	319.41	230.69							Fee Schedule		262.63							Fee Schedule																													319.41							Fee Schedule																																															
HARMONIC SCALPEL LCSB5	272	RC						Both			1150.8	517.86	517.86	1035.72	748.02							Fee Schedule		851.59							Fee Schedule																													1035.72							Fee Schedule																																															
HARMONIC SCALPEL SUTURE ASSIST SW100	272	RC						Both			494.55	222.55	222.55	445.1	321.46							Fee Schedule		365.97							Fee Schedule																													445.1							Fee Schedule																																															
HAVRIX 1440 EL.UNIT/ML VACCINE ADULT	636	RC	90632	CPT				Both			95.55	43	43	86		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	70.71							Fee Schedule		78.01							Fee Schedule		81.13							Fee Schedule											86							Fee Schedule																																															
HAVRIX 720 EL. UNITS/0.5 ML VACCINE PED	636	RC	90633	CPT				Both			58.8	26.46	26.46	87.1		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	43.51							Fee Schedule											40.58							Fee Schedule		75.74							Fee Schedule		52.92							Fee Schedule		87.1							Fee Schedule		70.43							Fee Schedule											87.1							Fee Schedule		70.43							Fee Schedule		
HAWKINS-AKINS NEEDLE 18-10.0 G05046	272	RC						Both			120.81	54.36	54.36	108.73	78.53							Fee Schedule		89.4							Fee Schedule																													108.73							Fee Schedule																																															
HAWKINS-AKINS NEEDLE 18-15.0 G05045	272	RC						Both			107	48.15	48.15	96.3	69.55							Fee Schedule		79.18							Fee Schedule																													96.3							Fee Schedule																																															
HAWKONE ATHERECTOMY SYSTEM H1-LX	272	RC						Both			10935	4920.75	4920.75	9841.5	7107.75							Fee Schedule		8091.9							Fee Schedule																													9841.5							Fee Schedule																																															
HAWKONE ATHERECTOMY SYSTEM H1-M	272	RC						Both			10935	4920.75	4920.75	9841.5	7107.75							Fee Schedule		8091.9							Fee Schedule																													9841.5							Fee Schedule																																															
H-BIG (BAYHEP B) INJ-5ML	636	RC	90371	CPT				Both			1192.8	536.76	70.24	1073.52		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	70.24							Fee Schedule		141.06							Fee Schedule		175.89							Fee Schedule											1073.52							Fee Schedule																																															
HCTZ 12.5 MG (HYDROCHLOROTHIAZIDE) CAP	250	RC	A9270	CPT				Both			6.3	2.84	0.01	157.49	0.01							Fee Schedule		4.66							Fee Schedule																				136.95							Fee Schedule		5.67							Fee Schedule		157.49							Fee Schedule		127.37							Fee Schedule											157.49							Fee Schedule		127.37							Fee Schedule		
HCTZ 25 MG (HYDROCHLOROTHIAZIDE) TABLET	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
HCTZ 50 MG (HYDROCHLOROTHIAZIDE) TABLET	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
HDL HIGH DENSITY LIPOPROTEIN 608 SER	301	RC	83718	CPT				Both			47.25	21.26	7.29	42.53	7.29							Fee Schedule		9.1							Fee Schedule		8.44							Fee Schedule		8.19							Fee Schedule											42.53							Fee Schedule																				8.19							Fee Schedule																				
HE4 OVARIAN CANCER MONITORING 16500	301	RC	86305	CPT				Both			346.5	155.93	7.62	311.85	18.5							Fee Schedule		23.13							Fee Schedule		21.43							Fee Schedule		20.81							Fee Schedule		8.19							Fee Schedule		311.85							Fee Schedule		9.42							Fee Schedule		7.62							Fee Schedule		20.81							Fee Schedule		9.42							Fee Schedule		7.62							Fee Schedule		
HEAD CRADLE PPD-40400	271	RC						Both			15	6.75	6.75	23.93	9.75							Fee Schedule		11.1							Fee Schedule																				20.81							Fee Schedule		13.5							Fee Schedule		23.93							Fee Schedule		19.35							Fee Schedule											23.93							Fee Schedule		19.35							Fee Schedule		
HEAD POSITIONER NON081147	271	RC						Both			23	10.35	10.35	20.7	14.95							Fee Schedule		17.02							Fee Schedule																													20.7							Fee Schedule																																															
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITHOUT CC/MCC					358	DRG		Inpatient			47955.61	21580.02	21580.02	21580.02							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period	
HEARING SCREENING TEST	471	RC	92551	CPT				Both			199.5	89.78	9.74	199	10.99							Fee Schedule		147.63							Fee Schedule											9.74							Fee Schedule											179.55							Fee Schedule																				199							Per Diem																				
HEARING TEST AIR & BONE STUDY	471	RC	92553	CPT				Both			131.25	59.06	20.61	199	34.2							Fee Schedule		97.13							Fee Schedule											20.61							Fee Schedule											118.13							Fee Schedule																				199							Per Diem																				
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS W					371	DRG		Inpatient			52022.55	23410.15	23410.15	23410.15							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period	
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS W					372	DRG		Inpatient			42166.7	18975.02	18975.02	18975.02							0		No services performed during 15 month lookback period. 				1048.43	1048.43	1048.43	1 through 10									0		No services performed during 15 month lookback period				4497.45	4497.45	4497.45	1 through 10									0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period	
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS W					373	DRG		Inpatient			28828.91	12973.01	12973.01	12973.01							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period	
HEART MONITOR	278	RC	93307	CPT				Both			1029	463.05	117.72	926.1	263	35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	761.46							Fee Schedule											117.72							Fee Schedule											926.1							Fee Schedule																																															
HEART MONITOR	730	RC	93041	CPT				Both			128.1	57.65	4.37	286	263							Per Diem		94.79							Fee Schedule											4.37							Fee Schedule											115.29							Fee Schedule																				286							Per Diem																				
HEAT PACK HCS1122	270	RC	A9273	CPT				Both			3	1.35	1.35	6.27	6.27							Fee Schedule		2.22							Fee Schedule																													2.7							Fee Schedule																																															
HEAT THERAPY PAD 18X26 STY002062026	271	RC	E0249	CPT				Both			53	23.85	23.85	146.2	78.48							Fee Schedule		39.22							Fee Schedule		146.2							Fee Schedule																				47.7							Fee Schedule																																															
HEATED HIGH FLOW	270	RC						Both			283.5	127.58	127.58	255.15	184.28							Fee Schedule		209.79							Fee Schedule																				141.94							Fee Schedule		255.15							Fee Schedule		163.23							Fee Schedule		132							Fee Schedule											163.23							Fee Schedule		132							Fee Schedule		
HEATING PAD	270	RC						Both			44.1	19.85	19.85	39.69	28.67							Fee Schedule		32.63							Fee Schedule																													39.69							Fee Schedule																																															
HEATING PAD #038056000507	270	RC						Both			45	20.25	20.25	40.5	29.25							Fee Schedule		33.3							Fee Schedule																													40.5							Fee Schedule																																															
HEAVY METAL SCR 7655 HEP WHOLE BLOOD RT	301	RC	83015	CPT				Both			418.95	188.53	16.74	377.06	16.74							Fee Schedule		20.94							Fee Schedule		21.57							Fee Schedule		20.94							Fee Schedule											377.06							Fee Schedule																				20.94							Fee Schedule																				
HEAVY METAL SCR UR 24HR 36438  7ML 24HRU	301	RC	83015	CPT				Both			239.4	107.73	16.74	215.46	16.74							Fee Schedule		20.94							Fee Schedule		21.57							Fee Schedule		20.94							Fee Schedule		20.94							Fee Schedule		215.46							Fee Schedule		24.08							Fee Schedule		19.47							Fee Schedule		20.94							Fee Schedule		24.08							Fee Schedule		19.47							Fee Schedule		
HEAVY METAL SCR UR 7507 10 ML RANDOM URI	301	RC	83015	CPT				Both			239.4	107.73	16.74	215.46	16.74							Fee Schedule		20.94							Fee Schedule		21.57							Fee Schedule		20.94							Fee Schedule		20.94							Fee Schedule		215.46							Fee Schedule		24.08							Fee Schedule		19.47							Fee Schedule		20.94							Fee Schedule		24.08							Fee Schedule		19.47							Fee Schedule		
HEEL CUSH VIS SZ C	274	RC	L3485	CPT				Both			27.56	12.4	12.4	24.8		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	20.39							Fee Schedule																				20.94							Fee Schedule		24.8							Fee Schedule		24.08							Fee Schedule		19.47							Fee Schedule											24.08							Fee Schedule		19.47							Fee Schedule		
HEEL CUSH VIS SZ D	274	RC	L3485	CPT				Both			27.56	12.4	12.4	24.8		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	20.39							Fee Schedule																													24.8							Fee Schedule																																															
HEEL LIFT KIT  MED 081244185	270	RC						Both			13	5.85	5.85	11.7	8.45							Fee Schedule		9.62							Fee Schedule																													11.7							Fee Schedule																																															
HEEL LIFT KIT LG 928650	270	RC						Both			14	6.3	6.3	12.6	9.1							Fee Schedule		10.36							Fee Schedule																													12.6							Fee Schedule																																															
HEEL LIFT KIT SMALL 958648	270	RC						Both			14	6.3	6.3	12.6	9.1							Fee Schedule		10.36							Fee Schedule																													12.6							Fee Schedule																																															
HEEL LT	320	RC	73650	CPT				Both			315	141.75	13.64	318	15.6							Fee Schedule		17.07							Fee Schedule											13.64							Fee Schedule											283.5							Fee Schedule																				318							Per Diem																				
HEEL PROTECTOR	271	RC						Both			35.7	16.07	16.07	32.13	23.21							Fee Schedule		26.42							Fee Schedule																													32.13							Fee Schedule																																															
HEEL PROTECTOR #M3009	271	RC	E0191	CPT				Both			15	6.75	6.69	13.5	6.69							Fee Schedule		11.1							Fee Schedule		12.46							Fee Schedule																				13.5							Fee Schedule																																															
HEEL RT	320	RC	73650	CPT				Both			315	141.75	11.25	318	15.6							Fee Schedule		17.07							Fee Schedule											13.64							Fee Schedule		12.1							Fee Schedule		283.5							Fee Schedule		13.92							Fee Schedule		11.25							Fee Schedule		318							Per Diem		13.92							Fee Schedule		11.25							Fee Schedule		
HEEL WARMER INFANT #11460-010T	271	RC						Both			1	0.45	0.45	0.9	0.65							Fee Schedule		0.74							Fee Schedule																													0.9							Fee Schedule																																															
HEEL WARMER INFANT SENECA	271	RC						Both			3.31	1.49	1.49	2.98	2.15							Fee Schedule		2.45							Fee Schedule																													2.98							Fee Schedule																																															
HEEL WEDGES 21/2 IN WEITH 65444	274	RC	L3350	CPT				Both			39.9	17.96	10.15	35.91		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	29.53							Fee Schedule		29.11							Fee Schedule		10.15							Fee Schedule											35.91							Fee Schedule																																															
HEEL WEDGES 3 IN WEITH 60638	274	RC	L3350	CPT				Both			39.9	17.96	10.15	35.91		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	29.53							Fee Schedule		29.11							Fee Schedule		10.15							Fee Schedule		28.26							Fee Schedule		35.91							Fee Schedule		32.5							Fee Schedule		26.28							Fee Schedule											32.5							Fee Schedule		26.28							Fee Schedule		
HEELSTICK BABYLANCE BLUE #BLN	272	RC						Both			2.1	0.95	0.95	32.5	1.37							Fee Schedule		1.55							Fee Schedule																				28.26							Fee Schedule		1.89							Fee Schedule		32.5							Fee Schedule		26.28							Fee Schedule											32.5							Fee Schedule		26.28							Fee Schedule		
HEIMLICH VALVE #G05297	272	RC						Both			314	141.3	141.3	282.6	204.1							Fee Schedule		232.36							Fee Schedule																													282.6							Fee Schedule																																															
HELICO PYLORI AG STOOL 34838	300	RC	87338	CPT				Both			206.85	93.08	12.79	186.17	12.79							Fee Schedule		15.98							Fee Schedule		14.81							Fee Schedule		14.38							Fee Schedule											186.17							Fee Schedule																				14.38							Fee Schedule																				
HELIUM GAS FOR PFT #536051-001	270	RC						Both			677.25	304.76	13.37	609.53	440.21							Fee Schedule		501.17							Fee Schedule																				14.38							Fee Schedule		609.53							Fee Schedule		16.54							Fee Schedule		13.37							Fee Schedule											16.54							Fee Schedule		13.37							Fee Schedule		
HEMA CLIP	272	RC						Both			7.35	3.31	3.31	6.62	4.78							Fee Schedule		5.44							Fee Schedule																													6.62							Fee Schedule																																															
HEMA CLIP GALLBLADDER 544230 (WECK) SEN	272	RC						Both			175	78.75	78.75	157.5	113.75							Fee Schedule		129.5							Fee Schedule																													157.5							Fee Schedule																																															
HEMA CLIP LG WECK 544240  ( TELEFLEX )	272	RC						Both			103	46.35	46.35	92.7	66.95							Fee Schedule		76.22							Fee Schedule																													92.7							Fee Schedule																																															
HEMA CLIP MED WECK 544230  ( TELEFLEX )	272	RC						Both			103	46.35	46.35	92.7	66.95							Fee Schedule		76.22							Fee Schedule																													92.7							Fee Schedule																																															
HEMA CLIP XL WECK 544250  ( TELEFLEX )	272	RC						Both			85	38.25	38.25	76.5	55.25							Fee Schedule		62.9							Fee Schedule																													76.5							Fee Schedule																																															
HEMABATE 250MCG/ML INJ	636	RC	A9270	CPT				Both			1339.8	602.91	602.91	1205.82		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	991.45							Fee Schedule																													1205.82							Fee Schedule																																															
HEMASPAN	250	RC	A9270	CPT				Both			1.58	0.71	0.01	1.42	0.01							Fee Schedule		1.17							Fee Schedule																													1.42							Fee Schedule																																															
HEMATOCRIT	305	RC	85014	CPT				Both			38.85	17.48	2.11	34.97	2.11							Fee Schedule		2.63							Fee Schedule		2.44							Fee Schedule		2.37							Fee Schedule											34.97							Fee Schedule																				2.37							Fee Schedule																				
HEMATURIA 3WAY COUDE 20FR 2557H20	272	RC						Both			57	25.65	2.2	51.3	37.05							Fee Schedule		42.18							Fee Schedule																				2.37							Fee Schedule		51.3							Fee Schedule		2.73							Fee Schedule		2.2							Fee Schedule											2.73							Fee Schedule		2.2							Fee Schedule		
HEMATURIA 3WAY COUDE 22FR 2557H22	272	RC						Both			57	25.65	25.65	51.3	37.05							Fee Schedule		42.18							Fee Schedule																													51.3							Fee Schedule																																															
HEMATURIA 3WAY COUDE 24FR 2557H24	272	RC						Both			57	25.65	25.65	51.3	37.05							Fee Schedule		42.18							Fee Schedule																													51.3							Fee Schedule																																															
HEMAVAC BARD MEDICAL 0043630	272	RC						Both			19	8.55	8.55	17.1	12.35							Fee Schedule		14.06							Fee Schedule																													17.1							Fee Schedule																																															
HEMAVAC DRAIN TUBING 00150002210 (ZIMMER	272	RC						Both			96.6	43.47	43.47	86.94	62.79							Fee Schedule		71.48							Fee Schedule																													86.94							Fee Schedule																																															
HEMAVAC MICROTEK #8410	272	RC						Both			68.25	30.71	30.71	61.43	44.36							Fee Schedule		50.51							Fee Schedule																													61.43							Fee Schedule																																															
HEMAVAC SNYDER #00-1500-023-10 (ZIMMER)	272	RC						Both			85.05	38.27	38.27	76.55	55.28							Fee Schedule		62.94							Fee Schedule																													76.55							Fee Schedule																																															
HEMAVAC SNYDER #2560-000-10 (ZIMMER)	272	RC						Both			197.4	88.83	88.83	177.66	128.31							Fee Schedule		146.08							Fee Schedule																													177.66							Fee Schedule																																															
HEMAVAC SNYDER 2500-000-10	272	RC						Both			256.2	115.29	115.29	230.58	166.53							Fee Schedule		189.59							Fee Schedule																													230.58							Fee Schedule																																															
HEMAVAC SNYDER 2505-000-10	272	RC						Both			221.55	99.7	99.7	199.4	144.01							Fee Schedule		163.95							Fee Schedule																													199.4							Fee Schedule																																															
HEMI HIP HEAD	278	RC						Both			759.15	341.62	341.62	683.24		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	561.77							Fee Schedule																													683.24							Fee Schedule																																															
HEMI SLING	271	RC						Both			34.65	15.59	15.59	31.19	22.52							Fee Schedule		25.64							Fee Schedule																													31.19							Fee Schedule																																															
HEMOCHROMATOSIS 35079 SPECIAL INSTRUCT	310	RC	81256	CPT				Both			351.75	158.29	58.1	316.58	58.1							Fee Schedule		72.62							Fee Schedule		67.32							Fee Schedule		65.36							Fee Schedule											316.58							Fee Schedule																																															
HEMOCLIP INSTANCE ENDO. (G18343) G58010	272	RC						Both			690	310.5	60.78	621	448.5							Fee Schedule		510.6							Fee Schedule																				65.36							Fee Schedule		621							Fee Schedule		75.16							Fee Schedule		60.78							Fee Schedule											75.16							Fee Schedule		60.78							Fee Schedule		
HEMOCYTE PLUS	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
HEMOGLOBIN	305	RC	85018	CPT				Both			65.1	29.3	2.11	58.59	2.11							Fee Schedule		2.63							Fee Schedule		2.44							Fee Schedule		2.37							Fee Schedule											58.59							Fee Schedule																				2.37							Fee Schedule																				
HEMOGLOBIN ELECTROPHORESIS 35489 EDTA	301	RC	83020	CPT				Both			158.55	71.35	2.2	142.7	11.44							Fee Schedule		14.3							Fee Schedule		13.26							Fee Schedule		12.87							Fee Schedule		2.37							Fee Schedule		142.7							Fee Schedule		2.73							Fee Schedule		2.2							Fee Schedule		12.87							Fee Schedule		2.73							Fee Schedule		2.2							Fee Schedule		
HEMOGLOBIN F FETAL 513 EDTA	301	RC	83030	CPT				Both			29.4	13.23	7.73	26.46	7.73							Fee Schedule		10.74							Fee Schedule		11.06							Fee Schedule		10.74							Fee Schedule		12.87							Fee Schedule		26.46							Fee Schedule		14.8							Fee Schedule		11.97							Fee Schedule		10.74							Fee Schedule		14.8							Fee Schedule		11.97							Fee Schedule		
HEMORRHAGE OCCLUDER PIN   CR1007	272	RC						Both			1343	604.35	9.99	1208.7	872.95							Fee Schedule		993.82							Fee Schedule																				10.74							Fee Schedule		1208.7							Fee Schedule		12.35							Fee Schedule		9.99							Fee Schedule											12.35							Fee Schedule		9.99							Fee Schedule		
HEMORRHOID LIGATOR #100225	272	RC						Both			151	67.95	67.95	135.9	98.15							Fee Schedule		111.74							Fee Schedule																													135.9							Fee Schedule																																															
HEMORRHOID LIGATOR BANDS 28-155 NEW	272	RC						Both			2	0.9	0.9	1.8	1.3							Fee Schedule		1.48							Fee Schedule																													1.8							Fee Schedule																																															
HEMORRHOIDAL OINTMENT- 60GM	250	RC	A9270	CPT				Both			8.82	3.97	0.01	7.94	0.01							Fee Schedule		6.53							Fee Schedule																													7.94							Fee Schedule																																															
HEMOSIDERIN STAIN URINE 518 30ML	301	RC	83070	CPT				Both			42	18.9	4.22	37.8	4.22							Fee Schedule		5.27							Fee Schedule		4.89							Fee Schedule		4.75							Fee Schedule											37.8							Fee Schedule																				4.75							Fee Schedule																				
HEMOSPLIT CATH. 15CM #5733150 (BARD PER	278	RC	C1750	CPT				Both			1420.65	639.29	4.42	1278.59		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1051.28							Fee Schedule																				4.75							Fee Schedule		1278.59							Fee Schedule		5.46							Fee Schedule		4.42							Fee Schedule											5.46							Fee Schedule		4.42							Fee Schedule		
HEMOSPLIT CATH. 19CM #5733690 (BARD PERI	278	RC	C1750	CPT				Both			1149.75	517.39	517.39	1034.78		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	850.82							Fee Schedule																													1034.78							Fee Schedule																																															
HEMOSPLIT CATH. 23CM #5733730 (BARD PERI	278	RC	C1750	CPT				Both			1149.75	517.39	517.39	1034.78		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	850.82							Fee Schedule																													1034.78							Fee Schedule																																															
HEMOSPRAY 10 FR. G21049 OR HEMO-10	272	RC	C1052	CPT				Both			6142.5	2764.13	2764.13	5528.25	3992.63							Fee Schedule		4545.45							Fee Schedule																													5528.25							Fee Schedule																																															
HEMOSPRAY 7 FR. G56572 OR HEMO-7	272	RC	C1052	CPT				Both			7500	3375	3375	6750	4875							Fee Schedule		5550							Fee Schedule																													6750							Fee Schedule																																															
HEP A  AB IGM 512	302	RC	86709	CPT				Both			79.8	35.91	10.01	71.82	10.01							Fee Schedule		12.51							Fee Schedule		11.6							Fee Schedule		11.26							Fee Schedule											71.82							Fee Schedule																				11.26							Fee Schedule																				
HEP A AB TOTAL 508 SERUM	302	RC	86708	CPT				Both			84	37.8	10.47	75.6	11.01							Fee Schedule		13.76							Fee Schedule		12.76							Fee Schedule		12.39							Fee Schedule		11.26							Fee Schedule		75.6							Fee Schedule		12.95							Fee Schedule		10.47							Fee Schedule		12.39							Fee Schedule		12.95							Fee Schedule		10.47							Fee Schedule		
HEP B CORE AB 501 SERUM	302	RC	86704	CPT				Both			71.4	32.13	10.71	64.26	10.71							Fee Schedule		13.39							Fee Schedule		12.41							Fee Schedule		12.05							Fee Schedule		12.39							Fee Schedule		64.26							Fee Schedule		14.25							Fee Schedule		11.52							Fee Schedule		12.05							Fee Schedule		14.25							Fee Schedule		11.52							Fee Schedule		
HEP B CORE AB IGM 4848	302	RC	86705	CPT				Both			74.55	33.55	10.47	67.1	10.47							Fee Schedule		13.08							Fee Schedule		12.12							Fee Schedule		11.77							Fee Schedule		12.05							Fee Schedule		67.1							Fee Schedule		13.86							Fee Schedule		11.21							Fee Schedule		11.77							Fee Schedule		13.86							Fee Schedule		11.21							Fee Schedule		
HEP B E AB 556 SERUM 1ML	302	RC	86707	CPT				Both			72.45	32.6	10.28	65.21	10.28							Fee Schedule		12.85							Fee Schedule		11.92							Fee Schedule		11.57							Fee Schedule		11.77							Fee Schedule		65.21							Fee Schedule		13.54							Fee Schedule		10.95							Fee Schedule		11.57							Fee Schedule		13.54							Fee Schedule		10.95							Fee Schedule		
HEP B E AG 555 SERUM 1ML	306	RC	87350	CPT				Both			85.05	38.27	10.25	76.55	10.25							Fee Schedule		12.81							Fee Schedule		11.88							Fee Schedule		11.53							Fee Schedule		11.57							Fee Schedule		76.55							Fee Schedule		13.31							Fee Schedule		10.76							Fee Schedule		11.53							Fee Schedule		13.31							Fee Schedule		10.76							Fee Schedule		
HEP B SURFACE AB 499 1ML SERUM	302	RC	86706	CPT				Both			109.2	49.14	9.55	98.28	9.55							Fee Schedule		11.93							Fee Schedule		11.06							Fee Schedule		10.74							Fee Schedule		11.53							Fee Schedule		98.28							Fee Schedule		13.26							Fee Schedule		10.72							Fee Schedule		10.74							Fee Schedule		13.26							Fee Schedule		10.72							Fee Schedule		
HEP B SURFACE AB QUAN 8475 1ML SERUM	302	RC	86706	CPT				Both			109.2	49.14	9.55	98.28	9.55							Fee Schedule		11.93							Fee Schedule		11.06							Fee Schedule		10.74							Fee Schedule		10.74							Fee Schedule		98.28							Fee Schedule		12.35							Fee Schedule		9.99							Fee Schedule		10.74							Fee Schedule		12.35							Fee Schedule		9.99							Fee Schedule		
HEP B SURFACE AG - SEND TO TENNOVA	306	RC	87340	CPT				Both			123.9	55.76	9.18	111.51	9.18							Fee Schedule		11.48							Fee Schedule		10.64							Fee Schedule		10.33							Fee Schedule		10.74							Fee Schedule		111.51							Fee Schedule		12.35							Fee Schedule		9.99							Fee Schedule		10.33							Fee Schedule		12.35							Fee Schedule		9.99							Fee Schedule		
HEP B SURFACE AG 498 HBSAG SERUM	306	RC	87340	CPT				Both			123.9	55.76	9.18	111.51	9.18							Fee Schedule		11.48							Fee Schedule		10.64							Fee Schedule		10.33							Fee Schedule		10.33							Fee Schedule		111.51							Fee Schedule		11.88							Fee Schedule		9.61							Fee Schedule		10.33							Fee Schedule		11.88							Fee Schedule		9.61							Fee Schedule		
HEP B VIRAL DNA 8369 3ML FRZ PLASMA	300	RC	87517	CPT				Both			388.5	174.83	9.61	349.65	38.07							Fee Schedule		47.6							Fee Schedule		44.13							Fee Schedule		42.84							Fee Schedule		10.33							Fee Schedule		349.65							Fee Schedule		11.88							Fee Schedule		9.61							Fee Schedule		42.84							Fee Schedule		11.88							Fee Schedule		9.61							Fee Schedule		
HEP C ANTIBODY 8472 SERUM	302	RC	86803	CPT				Both			78.75	35.44	12.68	70.88	12.68							Fee Schedule		15.85							Fee Schedule		14.7							Fee Schedule		14.27							Fee Schedule		42.84							Fee Schedule		70.88							Fee Schedule		49.27							Fee Schedule		39.84							Fee Schedule		14.27							Fee Schedule		49.27							Fee Schedule		39.84							Fee Schedule		
HEP C GENOTYPE3 NS5a DRG RES 93325	306	RC	87902	CPT				Both			971.25	437.06	13.27	874.13	228.84							Fee Schedule		286.05							Fee Schedule		265.17							Fee Schedule		257.45							Fee Schedule		14.27							Fee Schedule		874.13							Fee Schedule		16.41							Fee Schedule		13.27							Fee Schedule		257.45							Fee Schedule		16.41							Fee Schedule		13.27							Fee Schedule		
HEP C GT1 NS5a 92447 EDTA LAV 2ML PLASMA	306	RC	87902	CPT				Both			971.25	437.06	228.84	874.13	228.84							Fee Schedule		286.05							Fee Schedule		265.17							Fee Schedule		257.45							Fee Schedule		257.45							Fee Schedule		874.13							Fee Schedule		296.07							Fee Schedule		239.43							Fee Schedule		257.45							Fee Schedule		296.07							Fee Schedule		239.43							Fee Schedule		
HEP C RNA QUANT 35645	306	RC	87522	CPT				Both			504	226.8	38.07	453.6	38.07							Fee Schedule		47.6							Fee Schedule		44.13							Fee Schedule		42.84							Fee Schedule		257.45							Fee Schedule		453.6							Fee Schedule		296.07							Fee Schedule		239.43							Fee Schedule		42.84							Fee Schedule		296.07							Fee Schedule		239.43							Fee Schedule		
"HEP C VIRAL RNA, GENOTYPE LIPA 37811"	306	RC	87902	CPT				Both			1130	508.5	39.84	1017	228.84							Fee Schedule		286.05							Fee Schedule		265.17							Fee Schedule		257.45							Fee Schedule		42.84							Fee Schedule		1017							Fee Schedule		49.27							Fee Schedule		39.84							Fee Schedule		257.45							Fee Schedule		49.27							Fee Schedule		39.84							Fee Schedule		
HEP DELTA AB 4990 SERUM	302	RC	86692	CPT				Both			84	37.8	15.26	296.07	15.26							Fee Schedule		19.07							Fee Schedule		17.67							Fee Schedule		17.16							Fee Schedule		257.45							Fee Schedule		75.6							Fee Schedule		296.07							Fee Schedule		239.43							Fee Schedule		17.16							Fee Schedule		296.07							Fee Schedule		239.43							Fee Schedule		
"HEPARIN  1,000 UNITS/ML-1 ML VIAL"	636	RC	J1644	CPT				Both			15.15	6.82	0.14	19.73		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	11.21							Fee Schedule		0.2							Fee Schedule		0.14							Fee Schedule		17.16							Fee Schedule		13.64							Fee Schedule		19.73							Fee Schedule		15.96							Fee Schedule											19.73							Fee Schedule		15.96							Fee Schedule		
"HEPARIN  1,000 UNITS/ML-10 ML VIAL"	636	RC	J1644	CPT				Both			28.6	12.87	0.14	25.74		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	21.16							Fee Schedule		0.2							Fee Schedule		0.14							Fee Schedule		0.2							Fee Schedule		25.74							Fee Schedule		0.23							Fee Schedule		0.19							Fee Schedule											0.23							Fee Schedule		0.19							Fee Schedule		
"HEPARIN  20,000 UNITS/ML VIAL"	636	RC	J1644	CPT				Both			48.17	21.68	0.14	43.35		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	35.65							Fee Schedule		0.2							Fee Schedule		0.14							Fee Schedule		0.2							Fee Schedule		43.35							Fee Schedule		0.23							Fee Schedule		0.19							Fee Schedule											0.23							Fee Schedule		0.19							Fee Schedule		
"HEPARIN  5,000 UNITS/ML VIAL"	636	RC	J1644	CPT				Both			12.6	5.67	0.14	11.34		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	9.32							Fee Schedule		0.2							Fee Schedule		0.14							Fee Schedule		0.2							Fee Schedule		11.34							Fee Schedule		0.23							Fee Schedule		0.19							Fee Schedule											0.23							Fee Schedule		0.19							Fee Schedule		
"HEPARIN 10,000 UNIT/ML-4 ML VIAL"	636	RC	J1644	CPT				Both			10.5	4.73	0.14	9.45		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	7.77							Fee Schedule		0.2							Fee Schedule		0.14							Fee Schedule		0.2							Fee Schedule		9.45							Fee Schedule		0.23							Fee Schedule		0.19							Fee Schedule											0.23							Fee Schedule		0.19							Fee Schedule		
"HEPARIN 20,000 UNITS/500ML PREMIX IVPB"	636	RC	J1644	CPT				Both			47.25	21.26	0.14	42.53		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	34.97							Fee Schedule		0.2							Fee Schedule		0.14							Fee Schedule		0.2							Fee Schedule		42.53							Fee Schedule		0.23							Fee Schedule		0.19							Fee Schedule											0.23							Fee Schedule		0.19							Fee Schedule		
"HEPARIN 20,000 UNITS/D5W 500ML"	636	RC	J1644	CPT				Both			59.7	26.87	0.14	53.73		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	44.18							Fee Schedule		0.2							Fee Schedule		0.14							Fee Schedule		0.2							Fee Schedule		53.73							Fee Schedule		0.23							Fee Schedule		0.19							Fee Schedule											0.23							Fee Schedule		0.19							Fee Schedule		
HEPARIN 25000 UNITS/250ML D5W PREMIX	636	RC	J1644	CPT				Both			38.56	17.35	0.14	34.7		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	28.53							Fee Schedule		0.2							Fee Schedule		0.14							Fee Schedule		0.2							Fee Schedule		34.7							Fee Schedule		0.23							Fee Schedule		0.19							Fee Schedule											0.23							Fee Schedule		0.19							Fee Schedule		
HEPARIN ANTI-Xa  404 PLASMA 2ML FZ	302	RC	85520	CPT				Both			220.5	99.23	0.19	198.45	11.64							Fee Schedule		14.55							Fee Schedule		13.48							Fee Schedule		13.09							Fee Schedule		0.2							Fee Schedule		198.45							Fee Schedule		0.23							Fee Schedule		0.19							Fee Schedule		13.09							Fee Schedule		0.23							Fee Schedule		0.19							Fee Schedule		
HEPARIN INDUCED PLT AB 414 SERUM 2ML FZ	302	RC	86022	CPT				Both			267.75	120.49	12.17	240.98	16.33							Fee Schedule		20.41							Fee Schedule		18.92							Fee Schedule		18.37							Fee Schedule		13.09							Fee Schedule		240.98							Fee Schedule		15.05							Fee Schedule		12.17							Fee Schedule		18.37							Fee Schedule		15.05							Fee Schedule		12.17							Fee Schedule		
HEPARIN LOCK FLUSH 100UNITS/ML-5ML SYRIN	636	RC	J1642	CPT				Both			11.13	5.01	0.02	21.13		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	8.24							Fee Schedule		0.02							Fee Schedule		0.68							Fee Schedule		18.37							Fee Schedule		10.02							Fee Schedule		21.13							Fee Schedule		17.08							Fee Schedule											21.13							Fee Schedule		17.08							Fee Schedule		
HEPARIN LOCK FLUSH 10UNITS/ML-5ML SYRIN	636	RC						Both			10.83	4.87	0.02	9.75		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	8.01							Fee Schedule																				0.02							Fee Schedule		9.75							Fee Schedule		0.02							Fee Schedule		0.02							Fee Schedule											0.02							Fee Schedule		0.02							Fee Schedule		
HEPARIN PREMIX	258	RC						Both			21	9.45	9.45	18.9	13.65							Fee Schedule		15.54							Fee Schedule																													18.9							Fee Schedule																																															
HEPATIC FUNCTION PANEL	301	RC	80076	CPT				Both			158.55	71.35	7.26	142.7	7.26							Fee Schedule		9.08							Fee Schedule		8.42							Fee Schedule		8.17							Fee Schedule											142.7							Fee Schedule																				8.17							Fee Schedule																				
HEPATITIS A VACCINE	636	RC	90632	CPT				Both			201.6	90.72	7.6	181.44		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	149.18							Fee Schedule		78.01							Fee Schedule		81.13							Fee Schedule		8.17							Fee Schedule		181.44							Fee Schedule		9.4							Fee Schedule		7.6							Fee Schedule											9.4							Fee Schedule		7.6							Fee Schedule		
HEPATITIS E VIRUS IGG/IGM 15085 1ML SERU	302	RC	86790	CPT				Both			168	75.6	11.45	151.2	11.45							Fee Schedule		14.31							Fee Schedule		13.27							Fee Schedule		12.88							Fee Schedule		75.74							Fee Schedule		151.2							Fee Schedule		87.1							Fee Schedule		70.43							Fee Schedule		12.88							Fee Schedule		87.1							Fee Schedule		70.43							Fee Schedule		
DIGESTIVE MALIGNANCY WITH CC					375	DRG		Inpatient			19243.31	8659.49	8659.49	8659.49							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0	Fee Schedule	No services provided during 15 month lookback period							0	Fee Schedule	No services provided during 15 month lookback period							0		No services provided during 15 month lookback							0		No services provided during 15 month lookback period							0	Fee Schedule	No services provided during 15 month lookback period	
HEPLISAV-B (HEP B PED) 20MCG/0.5ML VAC	636	RC	90739	CPT				Both			506.16	227.77	193.86	455.54		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	374.56							Fee Schedule		193.86							Fee Schedule																				455.54							Fee Schedule																																															
HEP-LOCK   100 UNIT/ML-1ML VIAL	636	RC	J1642	CPT				Both			11.55	5.2	0.02	216.44		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	8.55							Fee Schedule		0.02							Fee Schedule		0.68							Fee Schedule		188.21							Fee Schedule		10.4							Fee Schedule		216.44							Fee Schedule		175.04							Fee Schedule											216.44							Fee Schedule		175.04							Fee Schedule		
HEPTIMAX (R) HCV RNA 10565 4 ML SER FZ.	306	RC	87522	CPT				Both			528.15	237.67	0.02	475.34	38.07							Fee Schedule		47.6							Fee Schedule		44.13							Fee Schedule		42.84							Fee Schedule		0.02							Fee Schedule		475.34							Fee Schedule		0.02							Fee Schedule		0.02							Fee Schedule		42.84							Fee Schedule		0.02							Fee Schedule		0.02							Fee Schedule		
HERCULES BALLOON #M00558610	272	RC	C1726	CPT				Both			668	300.6	39.84	601.2	135.94							Fee Schedule		494.32							Fee Schedule																				42.84							Fee Schedule		601.2							Fee Schedule		49.27							Fee Schedule		39.84							Fee Schedule											49.27							Fee Schedule		39.84							Fee Schedule		
HERCULES BALLOON CATHETER #M00558620	272	RC	C1726	CPT				Both			668	300.6	135.94	601.2	135.94							Fee Schedule		494.32							Fee Schedule																													601.2							Fee Schedule																																															
HERNIA BALLOON TROCAR # OMST10SB	272	RC						Both			700.35	315.16	315.16	630.32	455.23							Fee Schedule		518.26							Fee Schedule																													630.32							Fee Schedule																																															
HERNIA DIST. BALLOON # OMS-PBD1000	272	RC						Both			1298.85	584.48	584.48	1168.97	844.25							Fee Schedule		961.15							Fee Schedule																													1168.97							Fee Schedule																																															
HERNIA DIST. BALLOON # OMSPDBS2	272	RC						Both			1404.9	632.21	632.21	1264.41	913.19							Fee Schedule		1039.63							Fee Schedule																													1264.41							Fee Schedule																																															
DIGESTIVE MALIGNANCY WITHOUT CC/MCC					376	DRG		Inpatient			28690.98	12910.94	12910.94	12910.94							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback							0		No services provided during 15 month lookback period				1092	1092	1092	1 through 10			
GASTROINTESTINAL HEMORRHAGE WITH MCC					377	DRG		Inpatient			29848.57	13431.86	13431.86	13431.86							0		No services performed during 15 month lookback period. 				2041.89	2041.89	2041.89	1 through 10									0		No services performed during 15 month lookback period							0		No services provided during 15 month lookback period				9869.66	9869.66	9869.66	1 through 10									0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period	
GASTROINTESTINAL HEMORRHAGE WITH CC					378	DRG		Inpatient			29807.79	13413.51	13413.51	13413.51							0		No services performed during 15 month lookback period. 				2083.96	2070.73	4233.03	1 through 10									0		No services performed during 15 month lookback period				3752.16	3752.16	3752.16	1 through 10						5424.73	5424.73	5424.73	1 through 10									0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback				8199.6	8199.6	8199.6	1 through 10									0		No services provided during 15 month lookback period	
"HEROIN SCREEN, SER/PLASMA 3154"	301	RC	80307	CPT				Both			136.5	61.43	51.72	122.85	51.72							Fee Schedule		64.65							Fee Schedule		64							Fee Schedule		62.14							Fee Schedule											122.85							Fee Schedule																				62.14							Fee Schedule																				
HERPES 1/2 DNA  PCR 90569	311	RC	87529	CPT				Both			300	135	31.2	270	31.2							Fee Schedule		38.99							Fee Schedule		36.14							Fee Schedule		35.09							Fee Schedule		62.14							Fee Schedule		270							Fee Schedule		71.46							Fee Schedule		57.79							Fee Schedule											71.46							Fee Schedule		57.79							Fee Schedule		
HERPES CULTURE W 0 TYPING  2692 VCM TUBE	306	RC	87254	CPT				Both			110.25	49.61	17.39	99.23	17.39							Fee Schedule		21.73							Fee Schedule		20.15							Fee Schedule		19.56							Fee Schedule		35.09							Fee Schedule		99.23							Fee Schedule		40.35							Fee Schedule		32.63							Fee Schedule		19.56							Fee Schedule		40.35							Fee Schedule		32.63							Fee Schedule		
HERPES CULTURE W TYPING  2649 VCM TUBE	306	RC	87254	CPT				Both			191.1	86	17.39	171.99	17.39							Fee Schedule		21.73							Fee Schedule		20.15							Fee Schedule		19.56							Fee Schedule		19.56							Fee Schedule		171.99							Fee Schedule		22.49							Fee Schedule		18.19							Fee Schedule		19.56							Fee Schedule		22.49							Fee Schedule		18.19							Fee Schedule		
HERPES SIMPLEX 1&2 AB PCR 34257  CSF	306	RC	87529	CPT				Both			458.85	206.48	18.19	412.97	31.2							Fee Schedule		38.99							Fee Schedule		36.14							Fee Schedule		35.09							Fee Schedule		19.56							Fee Schedule		412.97							Fee Schedule		22.49							Fee Schedule		18.19							Fee Schedule		35.09							Fee Schedule		22.49							Fee Schedule		18.19							Fee Schedule		
HERPES SIMPLEX 1&2 PCR 34257  SERUM	306	RC	87529	CPT				Both			458.85	206.48	31.2	412.97	31.2							Fee Schedule		38.99							Fee Schedule		36.14							Fee Schedule		35.09							Fee Schedule		35.09							Fee Schedule		412.97							Fee Schedule		40.35							Fee Schedule		32.63							Fee Schedule		35.09							Fee Schedule		40.35							Fee Schedule		32.63							Fee Schedule		
HERPES VIRUS 6 DNA 16001 PCR EDTA  TUBE	302	RC	87532	CPT				Both			212.1	95.45	31.2	190.89	31.2							Fee Schedule		38.99							Fee Schedule		36.14							Fee Schedule		35.09							Fee Schedule		35.09							Fee Schedule		190.89							Fee Schedule		40.35							Fee Schedule		32.63							Fee Schedule		35.09							Fee Schedule		40.35							Fee Schedule		32.63							Fee Schedule		
HERPES VIRUS 8 DNA 15873 PCR EDTA  TUBE	302	RC	87798	CPT				Both			354.9	159.71	31.2	319.41	31.2							Fee Schedule		38.99							Fee Schedule		36.14							Fee Schedule		35.09							Fee Schedule		35.09							Fee Schedule		319.41							Fee Schedule		40.35							Fee Schedule		32.63							Fee Schedule		35.09							Fee Schedule		40.35							Fee Schedule		32.63							Fee Schedule		
HERPESVIRUS 6 AB (IGM) 34153	302	RC	86790	CPT				Both			102	45.9	11.45	91.8	11.45							Fee Schedule		14.31							Fee Schedule		13.27							Fee Schedule		12.88							Fee Schedule		35.09							Fee Schedule		91.8							Fee Schedule		40.35							Fee Schedule		32.63							Fee Schedule		12.88							Fee Schedule		40.35							Fee Schedule		32.63							Fee Schedule		
HESPAN (HETASTARCH) 6% 500ML	250	RC	A9270	CPT				Both			49.42	22.24	0.01	44.48	0.01							Fee Schedule		36.57							Fee Schedule																				12.88							Fee Schedule		44.48							Fee Schedule		14.81							Fee Schedule		11.98							Fee Schedule											14.81							Fee Schedule		11.98							Fee Schedule		
HESPAN 500 ML	250	RC						Both			92.4	41.58	41.58	83.16	60.06							Fee Schedule		68.38							Fee Schedule																													83.16							Fee Schedule																																															
HEWSON SUTURE RETRIEVER	272	RC						Both			541	243.45	243.45	486.9	351.65							Fee Schedule		400.34							Fee Schedule																													486.9							Fee Schedule																																															
HGB A1C	301	RC	83036	CPT				Both			97.65	43.94	8.63	87.89	8.63							Fee Schedule		10.79							Fee Schedule		10							Fee Schedule		9.71							Fee Schedule											87.89							Fee Schedule																				9.71							Fee Schedule																				
HIBERIX 0.5ML VACCINE SYRINGE	636	RC	90648	CPT				Both			45.63	20.53	9.03	41.07		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	33.77							Fee Schedule																				9.71							Fee Schedule		41.07							Fee Schedule		11.17							Fee Schedule		9.03							Fee Schedule											11.17							Fee Schedule		9.03							Fee Schedule		
HIBERIX 0.5ML VACCINE VIAL	636	RC	90648	CPT				Both			36.75	16.54	16.54	33.08		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	27.2							Fee Schedule																													33.08							Fee Schedule																																															
HIBICLENS 4.0%- 8 OZ.ANTISEPTIC SOLUTION	250	RC	A9270	CPT				Both			25.2	11.34	0.01	22.68	0.01							Fee Schedule		18.65							Fee Schedule																													22.68							Fee Schedule																																															
HIBICLENS 4.0% ANTISEPTIC SOLUTION-4OZ	250	RC	A9270	CPT				Both			18.9	8.51	0.01	17.01	0.01							Fee Schedule		13.99							Fee Schedule																													17.01							Fee Schedule																																															
HICKMAN CATH. #0600562 (BARD ACCESS)	272	RC						Both			623.7	280.67	280.67	561.33	405.41							Fee Schedule		461.54							Fee Schedule																													561.33							Fee Schedule																																															
HICKMAN CATH. 12.5 FR. # 0600560 ( BARD	278	RC	C1751	CPT				Both			464.1	208.85	208.85	417.69		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	343.43							Fee Schedule																													417.69							Fee Schedule																																															
HICKMAN CATH.#0600160 (BARD ACCESS)	272	RC						Both			529.2	238.14	238.14	476.28	343.98							Fee Schedule		391.61							Fee Schedule																													476.28							Fee Schedule																																															
HIGH FLO CIRCUIT ADULT W/ CHAMBER  AH202	270	RC	A4618	CPT				Both			73	32.85	4.33	65.7	6.81							Fee Schedule		54.02							Fee Schedule		11.1							Fee Schedule		4.33							Fee Schedule											65.7							Fee Schedule																																															
HIGH FLOW NASAL CAN  MED. 14934  AIRLIFE	270	RC	A4615	CPT				Both			67	30.15	0.66	60.3	0.66							Fee Schedule		49.58							Fee Schedule		1.07							Fee Schedule		0.82							Fee Schedule		10.78							Fee Schedule		60.3							Fee Schedule		12.4							Fee Schedule		10.03							Fee Schedule											12.4							Fee Schedule		10.03							Fee Schedule		
HIGH FLOW NASAL CAN LARG. 14935  AIRLIFE	270	RC	A4615	CPT				Both			66	29.7	0.66	59.4	0.66							Fee Schedule		48.84							Fee Schedule		1.07							Fee Schedule		0.82							Fee Schedule		1.04							Fee Schedule		59.4							Fee Schedule		1.2							Fee Schedule		0.97							Fee Schedule											1.2							Fee Schedule		0.97							Fee Schedule		
HIGH FLOW NASAL CAN SMALL 14933  AIRLIFE	270	RC	A4615	CPT				Both			66	29.7	0.66	59.4	0.66							Fee Schedule		48.84							Fee Schedule		1.07							Fee Schedule		0.82							Fee Schedule		1.04							Fee Schedule		59.4							Fee Schedule		1.2							Fee Schedule		0.97							Fee Schedule											1.2							Fee Schedule		0.97							Fee Schedule		
HIP 1V	320	RC	73501	CPT				Both			315	141.75	0.97	318	16.76							Fee Schedule		19.35							Fee Schedule											14.52							Fee Schedule		1.04							Fee Schedule		283.5							Fee Schedule		1.2							Fee Schedule		0.97							Fee Schedule		318							Per Diem		1.2							Fee Schedule		0.97							Fee Schedule		
HIP ABDUCTION ORTHOSIS CUSTOM	274	RC	L1686	CPT				Both			2804.55	1262.05	814.31	2524.1		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	2075.37							Fee Schedule		1178.84							Fee Schedule		814.31							Fee Schedule											2524.1							Fee Schedule																																															
GASTROINTESTINAL HEMORRHAGE WITHOUT CC/MCC					379	DRG		Inpatient			24351.75	10958.29	10958.29	10958.29							0		No services performed during 15 month lookback period. 				2412.87	2412.87	2412.87	1 through 10									0		No services performed during 15 month lookback period							0		No services provided during 15 month lookback period				2640.53	2640.53	2640.53	1 through 10									0		No services provided during 15 month lookback period							0	Fee Schedule	No services provided during 15 month lookback period				2695.96	2695.96	2695.96	1 through 10	Fee Schedule								0		No services provided during 15 month lookback							0		No services provided during 15 month lookback period							0	Fee Schedule	No services provided during 15 month lookback period	
COMPLICATED PEPTIC ULCER WITH MCC					380	DRG		Inpatient			47506.04	21377.72	21377.72	21377.72							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period	
COMPLICATED PEPTIC ULCER WITH CC					381	DRG		Inpatient			32277.05	14524.67	14524.67	14524.67							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period	
HIP BILAT 2 V EACH	320	RC	73521	CPT				Both			315	141.75	20.26	318	21.42							Fee Schedule		24.54							Fee Schedule											20.26							Fee Schedule											283.5							Fee Schedule																				318							Per Diem																				
HIP KIT REACHER P.T.  A665301 ( PATTERSO	270	RC						Both			40.95	18.43	18.43	36.86	26.62							Fee Schedule		30.3							Fee Schedule																													36.86							Fee Schedule																																															
HIP LT 2V	320	RC	73502	CPT				Both			315	141.75	21.83	318	24.62							Fee Schedule		28.76							Fee Schedule											21.83							Fee Schedule											283.5							Fee Schedule																				318							Per Diem																				
HIP LT SURG NAILING	320	RC	73502	CPT				Both			315	141.75	21.83	318	24.62							Fee Schedule		28.76							Fee Schedule											21.83							Fee Schedule											283.5							Fee Schedule																				318							Per Diem																				
HIP PACK NEW MEDLINE #DYNJS3011	270	RC						Both			229	103.05	103.05	206.1	148.85							Fee Schedule		169.46							Fee Schedule																													206.1							Fee Schedule																																															
COMPLICATED PEPTIC ULCER WITHOUT CC/MCC					382	DRG		Inpatient			17833	8024.85	8024.85	8024.85							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period	
HIP RT 2V	320	RC	73502	CPT				Both			315	141.75	21.83	318	24.62							Fee Schedule		28.76							Fee Schedule											21.83							Fee Schedule											283.5							Fee Schedule																				318							Per Diem																				
HIP RT SURG NAILING	320	RC	73502	CPT				Both			315	141.75	21.83	318	24.62							Fee Schedule		28.76							Fee Schedule											21.83							Fee Schedule											283.5							Fee Schedule																				318							Per Diem																				
HIP STEM CALCAR REPLACEMENT	278	RC						Both			2679.6	1205.82	1205.82	2411.64		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1982.9							Fee Schedule																													2411.64							Fee Schedule																																															
HIP STEM DRG	278	RC						Both			2679.6	1205.82	1205.82	2411.64		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1982.9							Fee Schedule																													2411.64							Fee Schedule																																															
HIP STEM HYDROXYAPP.	278	RC						Both			11325.3	5096.39	5096.39	10192.77		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	8380.72							Fee Schedule																													10192.77							Fee Schedule																																															
HIP STEM ODC	278	RC						Both			2679.6	1205.82	1205.82	2411.64		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1982.9							Fee Schedule																													2411.64							Fee Schedule																																															
HIP STEM ODC FX	278	RC	C1776	CPT				Both			2005.5	902.48	902.48	1804.95		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1484.07							Fee Schedule																													1804.95							Fee Schedule																																															
HIPSTER SIZE LARGE  (SENECA) #6019L	271	RC						Both			112.35	50.56	50.56	101.12	73.03							Fee Schedule		83.14							Fee Schedule																													101.12							Fee Schedule																																															
HIPSTER SIZE MEDIUM (SENECA) #6019M	271	RC						Both			112.35	50.56	50.56	101.12	73.03							Fee Schedule		83.14							Fee Schedule																													101.12							Fee Schedule																																															
HIPSTER SIZE SMALL (SENECA)#6019S	271	RC						Both			112.35	50.56	50.56	101.12	73.03							Fee Schedule		83.14							Fee Schedule																													101.12							Fee Schedule																																															
HIPSTER SIZE XLARGE (SENECA) #6019XL	271	RC						Both			112.35	50.56	50.56	101.12	73.03							Fee Schedule		83.14							Fee Schedule																													101.12							Fee Schedule																																															
HISTOCHEMICAL STAINING WITH FRZ SECTION	310	RC	88314	CPT				Both			199.5	89.78	41.01	179.55	41.01							Fee Schedule		63.18							Fee Schedule											60.5							Fee Schedule											179.55							Fee Schedule																																															
HISTOFREEZER CRYO SYSTEM #CH7154-G	271	RC						Both			23	10.35	10.35	20.7	14.95							Fee Schedule		17.02							Fee Schedule																													20.7							Fee Schedule																																															
HISTONE AB 37056 ANTIHISTONE ANTIBODIES	301	RC	83516	CPT				Both			187.95	84.58	10.25	169.16	10.25							Fee Schedule		12.81							Fee Schedule		11.88							Fee Schedule		11.53							Fee Schedule											169.16							Fee Schedule																				11.53							Fee Schedule																				
"HISTOPLASMA  ANTIGEN QN, UR OR BLD 58792"	300	RC	87385	CPT				Both			405	182.25	10.66	364.5	10.66							Fee Schedule		13.32							Fee Schedule		13.65							Fee Schedule		13.25							Fee Schedule		11.53							Fee Schedule		364.5							Fee Schedule		13.26							Fee Schedule		10.72							Fee Schedule		13.25							Fee Schedule		13.26							Fee Schedule		10.72							Fee Schedule		
"HISTOPLASMA  GALACTOMANNAN AG, UR 91212"	300	RC	87385	CPT				Both			206.85	93.08	10.66	186.17	10.66							Fee Schedule		13.32							Fee Schedule		13.65							Fee Schedule		13.25							Fee Schedule		13.25							Fee Schedule		186.17							Fee Schedule		15.24							Fee Schedule		12.32							Fee Schedule		13.25							Fee Schedule		15.24							Fee Schedule		12.32							Fee Schedule		
"HISTOPLASMA ANTIBODY, IMMNO 526"	302	RC	86698	CPT				Both			48	21.6	11.11	43.2	11.11							Fee Schedule		13.88							Fee Schedule		14.2							Fee Schedule		13.79							Fee Schedule		13.25							Fee Schedule		43.2							Fee Schedule		15.24							Fee Schedule		12.32							Fee Schedule		13.79							Fee Schedule		15.24							Fee Schedule		12.32							Fee Schedule		
HISTOPLASMIN DILUTED	250	RC						Both			10.84	4.88	4.88	15.86	7.05							Fee Schedule		8.02							Fee Schedule																				13.79							Fee Schedule		9.76							Fee Schedule		15.86							Fee Schedule		12.82							Fee Schedule											15.86							Fee Schedule		12.82							Fee Schedule		
HISTOPLASMOSIS AB 938 1ML SERUM	302	RC	86698	CPT				Both			88.2	39.69	11.11	79.38	11.11							Fee Schedule		13.88							Fee Schedule		14.2							Fee Schedule		13.79							Fee Schedule											79.38							Fee Schedule																				13.79							Fee Schedule																				
HIV 1 VIRAL LOAD PCR 40085 LAV 5ML  FRZ	306	RC	87536	CPT				Both			489.3	220.19	12.82	440.37	75.64							Fee Schedule		94.55							Fee Schedule		87.65							Fee Schedule		85.1							Fee Schedule		13.79							Fee Schedule		440.37							Fee Schedule		15.86							Fee Schedule		12.82							Fee Schedule		85.1							Fee Schedule		15.86							Fee Schedule		12.82							Fee Schedule		
HIV 1/2  AB/AG 91431 EMP	306	RC	87389	CPT				Both			142.8	64.26	21.41	128.52	21.41							Fee Schedule		26.75							Fee Schedule		24.8							Fee Schedule		24.08							Fee Schedule		85.1							Fee Schedule		128.52							Fee Schedule		97.87							Fee Schedule		79.14							Fee Schedule		24.08							Fee Schedule		97.87							Fee Schedule		79.14							Fee Schedule		
HIV II AB EIA 37363 SERUM 1ML	302	RC	86702	CPT				Both			223.65	100.64	12.02	201.29	12.02							Fee Schedule		15.02							Fee Schedule		13.93							Fee Schedule		13.52							Fee Schedule		24.08							Fee Schedule		201.29							Fee Schedule		27.69							Fee Schedule		22.39							Fee Schedule		13.52							Fee Schedule		27.69							Fee Schedule		22.39							Fee Schedule		
HLA  A29 DETERMINATION 12343	302	RC	81381	CPT				Both			555	249.75	12.57	499.5	122.33							Fee Schedule		169.9							Fee Schedule		175							Fee Schedule		169.9							Fee Schedule		13.52							Fee Schedule		499.5							Fee Schedule		15.55							Fee Schedule		12.57							Fee Schedule											15.55							Fee Schedule		12.57							Fee Schedule		
HLA B27  DNA TYPING BY PCR 15584	302	RC	86812	CPT				Both			147	66.15	22.94	195.39	22.94							Fee Schedule		28.67							Fee Schedule		26.58							Fee Schedule		25.81							Fee Schedule		169.9							Fee Schedule		132.3							Fee Schedule		195.39							Fee Schedule		158.01							Fee Schedule		25.81							Fee Schedule		195.39							Fee Schedule		158.01							Fee Schedule		
HLA B27 ANTIGEN  528	302	RC	86812	CPT				Both			124.95	56.23	22.94	112.46	22.94							Fee Schedule		28.67							Fee Schedule		26.58							Fee Schedule		25.81							Fee Schedule		25.81							Fee Schedule		112.46							Fee Schedule		29.68							Fee Schedule		24							Fee Schedule		25.81							Fee Schedule		29.68							Fee Schedule		24							Fee Schedule		
HLA TYPING 15484	302	RC	86813	CPT				Both			315	141.75	24	283.5	51.55							Fee Schedule		64.44							Fee Schedule		59.74							Fee Schedule		58							Fee Schedule		25.81							Fee Schedule		283.5							Fee Schedule		29.68							Fee Schedule		24							Fee Schedule		58							Fee Schedule		29.68							Fee Schedule		24							Fee Schedule		
HME FILTER W/ PORT STRAIGHT DYNJAPHME17	270	RC	A4483	CPT				Both			7	3.15	3.15	66.7	5							Fee Schedule		5.18							Fee Schedule																				58							Fee Schedule		6.3							Fee Schedule		66.7							Fee Schedule		53.94							Fee Schedule											66.7							Fee Schedule		53.94							Fee Schedule		
HME W/FILTER & SAMP. PORT (NEW) 301-1014	272	RC	A4483	CPT				Both			11	4.95	4.95	9.9	5							Fee Schedule		8.14							Fee Schedule																													9.9							Fee Schedule																																															
HMGCR ANTIBODY (IGG) 39044	301	RC	83520	CPT				Both			645	290.25	12.43	580.5	12.43							Fee Schedule		17.27							Fee Schedule		17.79							Fee Schedule		17.27							Fee Schedule											580.5							Fee Schedule																				17.27							Fee Schedule																				
HODGE PESSARY	272	RC						Both			103.95	46.78	16.06	93.56	67.57							Fee Schedule		76.92							Fee Schedule																				17.27							Fee Schedule		93.56							Fee Schedule		19.86							Fee Schedule		16.06							Fee Schedule											19.86							Fee Schedule		16.06							Fee Schedule		
HOLLI HEISIVE PASTE	271	RC						Both			23.1	10.4	10.4	20.79	15.02							Fee Schedule		17.09							Fee Schedule																													20.79							Fee Schedule																																															
HOLLIHESIVE PASTE	271	RC						Both			21	9.45	9.45	18.9	13.65							Fee Schedule		15.54							Fee Schedule																													18.9							Fee Schedule																																															
HOLLISTER OSTOMY KIT 19056	274	RC						Both			15	6.75	6.75	13.5		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	11.1							Fee Schedule																													13.5							Fee Schedule																																															
HOLLISTER SKIN BARR	271	RC						Both			56.7	25.52	25.52	51.03	36.86							Fee Schedule		41.96							Fee Schedule																													51.03							Fee Schedule																																															
HOLOGIC MYOSURE TISSUE REMOVE 10-401FC	272	RC						Both			2595	1167.75	1167.75	2335.5	1686.75							Fee Schedule		1920.3							Fee Schedule																													2335.5							Fee Schedule																																															
HOLOGIC MYOSURE TISSUE REMOVE 30-403LITE	272	RC						Both			1575	708.75	708.75	1417.5	1023.75							Fee Schedule		1165.5							Fee Schedule																													1417.5							Fee Schedule																																															
HOLTER MONITOR	731	RC	93225	CPT				Both			199.5	89.78	37.83	481	150							Per Diem		147.63							Fee Schedule											37.83							Fee Schedule											179.55							Fee Schedule																				481							Per Diem																				
HOLTER MONITOR KIT (KENDALL LTP)	271	RC						Both			18.9	8.51	8.51	17.01	12.29							Fee Schedule		13.99							Fee Schedule																													17.01							Fee Schedule																																															
HOLTER MONITOR SCAN	731	RC	93226	CPT				Both			280.35	126.16	66.61	481	150							Per Diem		207.46							Fee Schedule											66.61							Fee Schedule											252.32							Fee Schedule																				481							Per Diem																				
HOME SLEEP STUDY	920	RC	95806	CPT				Outpatient			2500	1125	150.07	2250	1300							Per Diem		1850							Fee Schedule											150.07							Fee Schedule											2250							Fee Schedule																				2122							Per Diem																				
HOME SLEEP STUDY PRIVATE PAY	920	RC	95806	CPT				Outpatient			375	168.75	97.77	2122	97.77							Fee Schedule	Not Reimbursed	277.5							Fee Schedule											150.07							Fee Schedule											337.5							Fee Schedule																				2122							Per Diem																				
HOMOCYSTINE 31789 1ML SERUM  SPC INSTR	301	RC	83090	CPT				Both			306.6	137.97	15	275.94	15							Fee Schedule		18.74							Fee Schedule		18.46							Fee Schedule		17.92							Fee Schedule											275.94							Fee Schedule																				17.92							Fee Schedule																				
HOMOVANILLIC ACID 530 HVA URINE 24 HR	301	RC	83150	CPT				Both			105	47.25	16.67	94.5	17.2							Fee Schedule		22.41							Fee Schedule		23.08							Fee Schedule		22.41							Fee Schedule		17.92							Fee Schedule		94.5							Fee Schedule		20.61							Fee Schedule		16.67							Fee Schedule		22.41							Fee Schedule		20.61							Fee Schedule		16.67							Fee Schedule		
HOOD DISPOSABLE INFANT UTM0300BX	270	RC						Both			61	27.45	20.84	54.9	39.65							Fee Schedule		45.14							Fee Schedule																				22.41							Fee Schedule		54.9							Fee Schedule		25.77							Fee Schedule		20.84							Fee Schedule											25.77							Fee Schedule		20.84							Fee Schedule		
HOOD DISPOSABLE INFANT UTM0305BX	270	RC						Both			69	31.05	31.05	62.1	44.85							Fee Schedule		51.06							Fee Schedule																													62.1							Fee Schedule																																															
HOPE NEBULIZER ADULT (TRIANIM)	271	RC						Both			37.8	17.01	17.01	34.02	24.57							Fee Schedule		27.97							Fee Schedule																													34.02							Fee Schedule																																															
HOW / OSTEO FEMORAL COMP #9 71-4509R	278	RC	C1776	CPT				Both			8274	3723.3	3723.3	7446.6		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	6122.76							Fee Schedule																													7446.6							Fee Schedule																																															
HOW FEMORAL COMPONENT 71-5111L	278	RC	C1776	CPT				Both			10501.05	4725.47	4725.47	9450.95		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	7770.78							Fee Schedule																													9450.95							Fee Schedule																																															
HOW PATELLA 73-0910	278	RC	C1776	CPT				Both			2847.6	1281.42	1281.42	2562.84		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	2107.22							Fee Schedule																													2562.84							Fee Schedule																																															
HOW TIBIA INSERT 72-3-1108	278	RC	C1776	CPT				Both			2007.6	903.42	903.42	1806.84		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1485.62							Fee Schedule																													1806.84							Fee Schedule																																															
HOW TIBIA TRAY 7115-0011	278	RC	C1776	CPT				Both			4876.2	2194.29	2194.29	4388.58		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	3608.39							Fee Schedule																													4388.58							Fee Schedule																																															
HOW/OSTEO SCORP.KNEE CRUCIATE#70-5107L	278	RC	C1776	CPT				Both			13087.2	5889.24	5889.24	11778.48		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	9684.53							Fee Schedule																													11778.48							Fee Schedule																																															
HOW/OSTEO TOT.KNEE TIB.TRAY#7115-0007	278	RC	C1776	CPT				Both			5971.35	2687.11	2687.11	5374.22		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	4418.8							Fee Schedule																													5374.22							Fee Schedule																																															
HOW\OSTEO COMPRESSION SCREW #375001	278	RC	C1713	CPT				Both			289.8	130.41	130.41	260.82		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	214.45							Fee Schedule																													260.82							Fee Schedule																																															
HOW\OSTEO FULL THREAD SCREW 35MM #376035	278	RC	C1713	CPT				Both			289.8	130.41	130.41	260.82		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	214.45							Fee Schedule																													260.82							Fee Schedule																																															
HOW\OSTEO IC TIBIAL NAIL #382376	278	RC						Both			2347.8	1056.51	1056.51	2113.02		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1737.37							Fee Schedule																													2113.02							Fee Schedule																																															
HOW\OSTEO PART.THREAD SCREW 45MM #375045	278	RC	C1713	CPT				Both			289.8	130.41	130.41	260.82		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	214.45							Fee Schedule																													260.82							Fee Schedule																																															
HOWMEDICA ACETABULAR SHELL 542-11-54F	278	RC	C1776	CPT				Both			5766.6	2594.97	2594.97	5189.94		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	4267.28							Fee Schedule																													5189.94							Fee Schedule																																															
HOWMEDICA BONE SCREW 2030-6525-1	278	RC	C1713	CPT				Both			2004.45	902	902	1804.01		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1483.29							Fee Schedule																													1804.01							Fee Schedule																																															
HOWMEDICA GAMMA NAIL K WIRE 1210-64550S	272	RC						Both			219.45	98.75	98.75	197.51	142.64							Fee Schedule		162.39							Fee Schedule																													197.51							Fee Schedule																																															
HOWMEDICA SECUR-FIT HIP STEM 6054-0915A	278	RC	C1776	CPT				Both			16159.5	7271.78	7271.78	14543.55		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	11958.03							Fee Schedule																													14543.55							Fee Schedule																																															
HOYTE SACRO TIP LG LH-SCOLPO-LRG	272	RC						Both			721	324.45	324.45	648.9	468.65							Fee Schedule		533.54							Fee Schedule																													648.9							Fee Schedule																																															
HOYTE SACRO TIP SM LH-SCOLPO-SML	272	RC						Both			721	324.45	324.45	648.9	468.65							Fee Schedule		533.54							Fee Schedule																													648.9							Fee Schedule																																															
HOYTE SACROCERV TIP LG LH-SCERV-LRG	272	RC						Both			721	324.45	324.45	648.9	468.65							Fee Schedule		533.54							Fee Schedule																													648.9							Fee Schedule																																															
HOYTE SACROCERV TIP SM LH-SCERV-SML	272	RC						Both			741	333.45	333.45	666.9	481.65							Fee Schedule		548.34							Fee Schedule																													666.9							Fee Schedule																																															
HSV-2 IGG INHIBITION 37529	302	RC	86696	CPT				Both			300	135	17.21	270	17.21							Fee Schedule		21.51							Fee Schedule		19.93							Fee Schedule		19.35							Fee Schedule											270							Fee Schedule																				19.35							Fee Schedule																				
HU ANTIBODY SCREEN 37053 SERUM 0.5 ML	302	RC	86255	CPT				Both			178.5	80.33	10.71	160.65	10.71							Fee Schedule		13.39							Fee Schedule		12.41							Fee Schedule		12.05							Fee Schedule		19.35							Fee Schedule		160.65							Fee Schedule		22.25							Fee Schedule		18							Fee Schedule		12.05							Fee Schedule		22.25							Fee Schedule		18							Fee Schedule		
HUMAN GROWTH HORMONE HGH 521 SERUM	301	RC	83003	CPT				Both			133.35	60.01	11.21	120.02	14.82							Fee Schedule		18.52							Fee Schedule		17.17							Fee Schedule		16.67							Fee Schedule		12.05							Fee Schedule		120.02							Fee Schedule		13.86							Fee Schedule		11.21							Fee Schedule		16.67							Fee Schedule		13.86							Fee Schedule		11.21							Fee Schedule		
HUMAN SECRETIN 16 MCG VIAL	636	RC	J2850	CPT				Both			1074.94	483.72	15.5	967.45		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	41.31							Fee Schedule		41.65							Fee Schedule											16.67							Fee Schedule		967.45							Fee Schedule		19.17							Fee Schedule		15.5							Fee Schedule											19.17							Fee Schedule		15.5							Fee Schedule		
HUMAN TRANSFORMING GF (TGF-B1) 91238	301	RC	83520	CPT				Both			210	94.5	12.43	189	12.43							Fee Schedule		17.27							Fee Schedule		17.79							Fee Schedule		17.27							Fee Schedule		40.44							Fee Schedule		189							Fee Schedule		46.5							Fee Schedule		37.61							Fee Schedule		17.27							Fee Schedule		46.5							Fee Schedule		37.61							Fee Schedule		
HUMERUS LT	320	RC	73060	CPT				Both			315	141.75	16.06	318	16.76							Fee Schedule		19.67							Fee Schedule											16.3							Fee Schedule		17.27							Fee Schedule		283.5							Fee Schedule		19.86							Fee Schedule		16.06							Fee Schedule		318							Per Diem		19.86							Fee Schedule		16.06							Fee Schedule		
HUMERUS RT	320	RC	73060	CPT				Both			315	141.75	16.3	318	16.76							Fee Schedule		19.67							Fee Schedule											16.3							Fee Schedule											283.5							Fee Schedule																				318							Per Diem																				
HUMIDIFIER  #002620/0552 HUD00540	272	RC						Both			6	2.7	2.7	5.4	3.9							Fee Schedule		4.44							Fee Schedule																													5.4							Fee Schedule																																															
HUMIDIFIER 700	272	RC						Both			15.75	7.09	7.09	14.18	10.24							Fee Schedule		11.66							Fee Schedule																													14.18							Fee Schedule																																															
HUMIDIFIER AL2502 (TRI-ANIM)	272	RC						Both			9.45	4.25	4.25	8.51	6.14							Fee Schedule		6.99							Fee Schedule																													8.51							Fee Schedule																																															
HUMIDIFIER KAZ 4100-HF	270	RC						Both			90	40.5	40.5	81	58.5							Fee Schedule		66.6							Fee Schedule																													81							Fee Schedule																																															
HUMMER IRRIGATION SET SINUS SURGERY	272	RC						Both			112.35	50.56	50.56	101.12	73.03							Fee Schedule		83.14							Fee Schedule																													101.12							Fee Schedule																																															
HUNTINGTON MUTATION ANALYSIS 5ML EDTA WB	300	RC	81401	CPT				Both			623.7	280.67	98.64	561.33	98.64							Fee Schedule		137							Fee Schedule		141.11							Fee Schedule		137							Fee Schedule											561.33							Fee Schedule																				137							Fee Schedule																				
HURRICAINE SPRAY- 2 OZ	250	RC	A9270	CPT				Both			95.55	43	0.01	157.55	0.01							Fee Schedule		70.71							Fee Schedule																				137							Fee Schedule		86							Fee Schedule		157.55							Fee Schedule		127.41							Fee Schedule											157.55							Fee Schedule		127.41							Fee Schedule		
HYALGAN 20 MG/2 ML SYRINGE	636	RC	J7321	CPT				Both			489.3	220.19	72.39	440.37		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	362.08							Fee Schedule		72.39							Fee Schedule																				440.37							Fee Schedule																																															
hydrALAZINE  10MG (APRESOLINE) TABLET	250	RC	A9270	CPT				Both			6.3	2.84	0.01	80.82	0.01							Fee Schedule		4.66							Fee Schedule																				70.28							Fee Schedule		5.67							Fee Schedule		80.82							Fee Schedule		65.36							Fee Schedule											80.82							Fee Schedule		65.36							Fee Schedule		
hydrALAZINE  25MG (APRESOLINE) TABLET	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
hydrALAZINE 100MG (APRESOLINE) TABLET	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
hydrALAZINE 20 MG/ML-1ML INJECTION	636	RC	J0360	CPT				Both			13.65	6.14	3.5	12.29		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	10.1							Fee Schedule		3.5							Fee Schedule		7.61							Fee Schedule											12.29							Fee Schedule																																															
HYDREA 500 MG CAP	250	RC	A9270	CPT				Both			5.25	2.36	0.01	4.73	0.01							Fee Schedule		3.89							Fee Schedule																				3.4							Fee Schedule		4.73							Fee Schedule		3.9							Fee Schedule		3.16							Fee Schedule											3.9							Fee Schedule		3.16							Fee Schedule		
HYDRO PC 2/5/2 SYRUP 5ML UD	250	RC	A9270	CPT				Both			5.25	2.36	0.01	4.73	0.01							Fee Schedule		3.89							Fee Schedule																													4.73							Fee Schedule																																															
HYDROCODONE SERUM 90489	301	RC	80306	CPT				Both			134.4	60.48	12.93	120.96	12.93							Fee Schedule		17.14							Fee Schedule		17.65							Fee Schedule		17.14							Fee Schedule											120.96							Fee Schedule																				17.14							Fee Schedule																				
HYDROCODONE/APAP (LORTAB)  5/500 MG TAB	250	RC	A9270	CPT				Both			6.3	2.84	0.01	19.71	0.01							Fee Schedule		4.66							Fee Schedule																				17.14							Fee Schedule		5.67							Fee Schedule		19.71							Fee Schedule		15.94							Fee Schedule											19.71							Fee Schedule		15.94							Fee Schedule		
HYDROCODONE/APAP (LORTAB) 10/500MG TAB	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
HYDROCODONE/APAP (LORTAB) 7.5/500 MG TAB	250	RC						Both			6.3	2.84	2.84	5.67	4.1							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
HYDROCODONE/APAP 10/325MG (LORTAB) TAB	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
HYDROCODONE/APAP 10/325MG TAB	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
HYDROCODONE/APAP 5/325 MG (LORTAB) TAB	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
HYDROCODONE/APAP 7.5/325 MG(LORTAB)TAB	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
HYDROCODONE/APAP 7.5/325MG/15ML U/D SOLN	250	RC	A9270	CPT				Both			12.6	5.67	0.01	11.34	0.01							Fee Schedule		9.32							Fee Schedule																													11.34							Fee Schedule																																															
HYDROCODONE/APAP 7.5/500 MG TABLET	250	RC	A9270	CPT				Both			5.25	2.36	0.01	4.73	0.01							Fee Schedule		3.89							Fee Schedule																													4.73							Fee Schedule																																															
HYDROCOLLOID DRESSING 2X2 MSC5422	272	RC	A6022	CPT				Both			2	0.9	0.9	30.87	18.93							Fee Schedule		1.48							Fee Schedule		30.87							Fee Schedule																				1.8							Fee Schedule																																															
HYDROCORTISONE 0.5% TOPICAL CREAM-30GM	250	RC	A9270	CPT				Both			10.5	4.73	0.01	34.47	0.01							Fee Schedule		7.77							Fee Schedule																				29.97							Fee Schedule		9.45							Fee Schedule		34.47							Fee Schedule		27.87							Fee Schedule											34.47							Fee Schedule		27.87							Fee Schedule		
HYDROCORTISONE 1% TOPICAL CREAM-30GM	250	RC	A9270	CPT				Both			8.51	3.83	0.01	7.66	0.01							Fee Schedule		6.3							Fee Schedule																													7.66							Fee Schedule																																															
HYDROCORTISONE 1% TOPICAL CREAM-UD	250	RC	A9270	CPT				Both			6	2.7	0.01	5.4	0.01							Fee Schedule		4.44							Fee Schedule																													5.4							Fee Schedule																																															
HYDROCORTISONE 1% TOPICAL LOTION-120ML	250	RC	A9270	CPT				Both			28.44	12.8	0.01	25.6	0.01							Fee Schedule		21.05							Fee Schedule																													25.6							Fee Schedule																																															
HYDROCORTISONE 10 MG TABLET	250	RC	A9270	CPT				Both			5.25	2.36	0.01	4.73	0.01							Fee Schedule		3.89							Fee Schedule																													4.73							Fee Schedule																																															
HYDROCORTISONE 2.5% TOPICAL CREAM-30GM	250	RC	A9270	CPT				Both			34.65	15.59	0.01	31.19	0.01							Fee Schedule		25.64							Fee Schedule																													31.19							Fee Schedule																																															
HYDROCORTISONE 2.5% TOPICAL OINTMENT	250	RC	A9270	CPT				Both			31.5	14.18	0.01	28.35	0.01							Fee Schedule		23.31							Fee Schedule																													28.35							Fee Schedule																																															
HYDROCORTISONE 25 MG REC SUPP(ANUSOL HC)	250	RC	A9270	CPT				Both			71.4	32.13	0.01	64.26	0.01							Fee Schedule		52.84							Fee Schedule																													64.26							Fee Schedule																																															
HYDROCORTONE 100 MG/2ML INJECTION	636	RC	J1710	CPT				Both			29.93	13.47	13.47	26.94		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	22.15							Fee Schedule																													26.94							Fee Schedule																																															
HYDROFERA BLUE DSG. 4X4 # HB4414	272	RC	A6209	CPT				Both			20	9	6.73	18	6.73							Fee Schedule		14.8							Fee Schedule		10.97							Fee Schedule		8.41							Fee Schedule											18							Fee Schedule																																															
HYDROFERA BLUE READY-BORDER 4X4 HBRB4040	272	RC	A6212	CPT				Both			28	12.6	8.74	25.2	8.74							Fee Schedule		20.72							Fee Schedule		14.26							Fee Schedule		10.93							Fee Schedule		10.65							Fee Schedule		25.2							Fee Schedule		12.25							Fee Schedule		9.9							Fee Schedule											12.25							Fee Schedule		9.9							Fee Schedule		
HYDROFERA BLUE TUNNEL 9MMX6  #HBT0906	272	RC	A6215	CPT				Both			23	10.35	4.66	20.7	4.66							Fee Schedule		17.02							Fee Schedule																				13.84							Fee Schedule		20.7							Fee Schedule		15.92							Fee Schedule		12.87							Fee Schedule											15.92							Fee Schedule		12.87							Fee Schedule		
HYDROGEL TUBE 3OZ  449600	272	RC	A6248	CPT				Both			15	6.75	6.75	23.84	14.63							Fee Schedule		11.1							Fee Schedule		23.84							Fee Schedule		18.29							Fee Schedule											13.5							Fee Schedule																																															
HYDROmorphone 1 MG/ML -(DILAUDID) PCA	636	RC	J1171	CPT				Both			76.65	34.49	0.14	68.99		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	56.72							Fee Schedule		0.14							Fee Schedule											23.15							Fee Schedule		68.99							Fee Schedule		26.62							Fee Schedule		21.53							Fee Schedule											26.62							Fee Schedule		21.53							Fee Schedule		
HYDROmorphone 1 MG/ML PCA: LOW DOSE	636	RC	J1171	CPT				Both			76.65	34.49	0.13	68.99		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	56.72							Fee Schedule		0.14							Fee Schedule											0.14							Fee Schedule		68.99							Fee Schedule		0.16							Fee Schedule		0.13							Fee Schedule											0.16							Fee Schedule		0.13							Fee Schedule		
HYDROmorphone 1 MG/ML-50ML PCA-QuVa	636	RC	J1171	CPT				Both			110.7	49.82	0.13	99.63		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	81.92							Fee Schedule		0.14							Fee Schedule											0.14							Fee Schedule		99.63							Fee Schedule		0.16							Fee Schedule		0.13							Fee Schedule											0.16							Fee Schedule		0.13							Fee Schedule		
HYDROMORPHONE 10982 2ML SERUM	301	RC	80307	CPT				Both			78.75	35.44	0.13	70.88	51.72							Fee Schedule		64.65							Fee Schedule		64							Fee Schedule		62.14							Fee Schedule		0.14							Fee Schedule		70.88							Fee Schedule		0.16							Fee Schedule		0.13							Fee Schedule		62.14							Fee Schedule		0.16							Fee Schedule		0.13							Fee Schedule		
HYDROMORPHONE 10MG/1ML VIAL-FOR PCA ONLY	636	RC	J1171	CPT				Both			16.92	7.61	0.14	71.46		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	12.52							Fee Schedule		0.14							Fee Schedule											62.14							Fee Schedule		15.23							Fee Schedule		71.46							Fee Schedule		57.79							Fee Schedule											71.46							Fee Schedule		57.79							Fee Schedule		
HYDROMORPHONE 500MG/50ML VL-FOR PCA ONLY	636	RC	J1171	CPT				Both			16.92	7.61	0.13	15.23		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	12.52							Fee Schedule		0.14							Fee Schedule											0.14							Fee Schedule		15.23							Fee Schedule		0.16							Fee Schedule		0.13							Fee Schedule											0.16							Fee Schedule		0.13							Fee Schedule		
HYDROMORPHONE 50MG/5ML VIAL-FOR PCA ONLY	636	RC	J1171	CPT				Both			39.21	17.64	0.13	35.29		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	29.02							Fee Schedule		0.14							Fee Schedule											0.14							Fee Schedule		35.29							Fee Schedule		0.16							Fee Schedule		0.13							Fee Schedule											0.16							Fee Schedule		0.13							Fee Schedule		
hydrOXY PAMOATE 25MG (VISTARIL) CAPSULE	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																				0.14							Fee Schedule		5.67							Fee Schedule		0.16							Fee Schedule		0.13							Fee Schedule											0.16							Fee Schedule		0.13							Fee Schedule		
hydrOXY PAMOATE 50MG (VISTARIL) CAPSULE	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
HYDROXYCHLOROQUINE 200MG (PLAQUENIL)TAB	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
HYDROXYCORTICOSTERIODS17 4932  24HR UA	301	RC	83593	CPT				Both			141.75	63.79	23.38	127.58	23.38							Fee Schedule		29.22							Fee Schedule		29.36							Fee Schedule		28.5							Fee Schedule											127.58							Fee Schedule																				28.5							Fee Schedule																				
HYDROXYPREGNENOLONE 8352 SERUM	301	RC	84143	CPT				Both			126	56.7	20.28	113.4	20.28							Fee Schedule		25.34							Fee Schedule		23.49							Fee Schedule		22.81							Fee Schedule		28.5							Fee Schedule		113.4							Fee Schedule		32.78							Fee Schedule		26.51							Fee Schedule		22.81							Fee Schedule		32.78							Fee Schedule		26.51							Fee Schedule		
HYDROXYPROGESTERONE 17180 SERUM	301	RC	83498	CPT				Both			147	66.15	21.21	132.3	24.15							Fee Schedule		30.19							Fee Schedule		27.99							Fee Schedule		27.17							Fee Schedule		22.81							Fee Schedule		132.3							Fee Schedule		26.23							Fee Schedule		21.21							Fee Schedule		27.17							Fee Schedule		26.23							Fee Schedule		21.21							Fee Schedule		
HYDROXYPROLINE FREE 37558 URINE 24HR	301	RC	83500	CPT				Both			126	56.7	20.13	113.4	20.13							Fee Schedule		25.17							Fee Schedule		23.33							Fee Schedule		22.65							Fee Schedule		27.17							Fee Schedule		113.4							Fee Schedule		31.25							Fee Schedule		25.27							Fee Schedule		22.65							Fee Schedule		31.25							Fee Schedule		25.27							Fee Schedule		
hydrOXYzine HCL 10MG (ATARAX) TABLET	250	RC	A9270	CPT				Both			6.3	2.84	0.01	26.05	0.01							Fee Schedule		4.66							Fee Schedule																				22.65							Fee Schedule		5.67							Fee Schedule		26.05							Fee Schedule		21.06							Fee Schedule											26.05							Fee Schedule		21.06							Fee Schedule		
hydrOXYzine HCL 25MG (ATARAX) TAB	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
hydrOXYzine HCL 25MG/1ML VIAL	636	RC	J3410	CPT				Both			76.65	34.49	0.64	68.99		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	56.72							Fee Schedule		15.67							Fee Schedule		0.64							Fee Schedule											68.99							Fee Schedule																																															
hydrOXYzine HCL 50MG/ML VIAL	636	RC	J3410	CPT				Both			21	9.45	0.64	18.9		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	15.54							Fee Schedule		15.67							Fee Schedule		0.64							Fee Schedule		15.21							Fee Schedule		18.9							Fee Schedule		17.49							Fee Schedule		14.14							Fee Schedule											17.49							Fee Schedule		14.14							Fee Schedule		
HydrOXYzine HCL SYRUP 10 MG/5ML	250	RC	A9270	CPT				Both			6	2.7	0.01	17.49	0.01							Fee Schedule		4.44							Fee Schedule																				15.21							Fee Schedule		5.4							Fee Schedule		17.49							Fee Schedule		14.14							Fee Schedule											17.49							Fee Schedule		14.14							Fee Schedule		
HYDROXYZINE PAMOATE 25 MG/5 ML SUSP UD	250	RC	Q0177	CPT				Both			19.25	8.66	0.1	17.33	0.1							Fee Schedule		14.25							Fee Schedule																													17.33							Fee Schedule																																															
HYGROSCOPIC HUMIDIF	272	RC						Both			11.55	5.2	5.2	10.4	7.51							Fee Schedule		8.55							Fee Schedule																													10.4							Fee Schedule																																															
HYGROTON 25 MG TAB	250	RC	A9270	CPT				Both			4.2	1.89	0.01	3.78	0.01							Fee Schedule		3.11							Fee Schedule																													3.78							Fee Schedule																																															
HYLENEX 150 UNITS/ML SDV	636	RC	J3473	CPT				Both			210	94.5	0.37	189		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	155.4							Fee Schedule		0.37							Fee Schedule																				189							Fee Schedule																																															
HYLUTIN 250MG/5ML(DONT CARRY)	636	RC						Both			45.15	20.32	0.34	40.64		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	33.41							Fee Schedule																				0.36							Fee Schedule		40.64							Fee Schedule		0.42							Fee Schedule		0.34							Fee Schedule											0.42							Fee Schedule		0.34							Fee Schedule		
HYOSCAMINE 0.375MG ER (LEVSINEX) TABLET	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
HYOSCYAMINE 0.125MG (LEVSIN) ODT TABLET	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
HYOSCYAMNE ORAL DROPS	250	RC	A9270	CPT				Both			137.55	61.9	0.01	123.8	0.01							Fee Schedule		101.79							Fee Schedule																													123.8							Fee Schedule																																															
HYPAQUE 50/50CC	636	RC	Q9962	CPT				Both			18.9	8.51	8.51	17.01		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	13.99							Fee Schedule																													17.01							Fee Schedule																																															
HYPERRAB IMMUNE GLOBULIN 300UNITS/ML-1ML	636	RC	90375	CPT				Both			2449.8	1102.41	99.79	2204.82		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	275.18							Fee Schedule		289.62							Fee Schedule		99.79							Fee Schedule											2204.82							Fee Schedule																																															
HYPER-SAL 7% 4ML AEROSOL UD  (RT)	250	RC	A9270	CPT				Both			5.25	2.36	0.01	323.36	0.01							Fee Schedule		3.89							Fee Schedule																				281.19							Fee Schedule		4.73							Fee Schedule		323.36							Fee Schedule		261.5							Fee Schedule											323.36							Fee Schedule		261.5							Fee Schedule		
HYPERSTAT 300 MG/20ML VIAL	636	RC	J1730	CPT				Both			444.15	199.87	199.87	399.74		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	328.67							Fee Schedule																													399.74							Fee Schedule																																															
UNCOMPLICATED PEPTIC ULCER WITH MCC					383	DRG		Inpatient			41333.8	18600.21	18600.21	18600.21							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period	
UNCOMPLICATED PEPTIC ULCER WITHOUT MCC					384	DRG		Inpatient			22109.4	9949.23	9949.23	9949.23							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period	
HYPERTET 25 UNITS SYRINGE	250	RC	J1670	CPT				Both			441	198.45	33.74	606.2	462.99							Fee Schedule		558.12							Fee Schedule		606.2							Fee Schedule		33.74							Fee Schedule											396.9							Fee Schedule																																															
"HYPOGLYCEMIC PANEL, SER/PLASMA 19595"	305	RC	80377	CPT				Both			336	151.2	0.01	676.82	0.01							Fee Schedule									Other	No Additional Reimbursement 																			588.54							Fee Schedule		302.4							Fee Schedule		676.82							Fee Schedule		547.34							Fee Schedule											676.82							Fee Schedule		547.34							Fee Schedule		
HYPOTEARS OPTH SOLUTION- 15ML	250	RC	A9270	CPT				Both			26.68	12.01	0.01	24.01	0.01							Fee Schedule		19.74							Fee Schedule																													24.01							Fee Schedule																																															
HYSKON:100ML.	636	RC	A4641	CPT				Both			100.8	45.36	45.36	90.72		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	74.59							Fee Schedule																													90.72							Fee Schedule																																															
HYSTERSALPINOGRAPHY	329	RC	74740	CPT				Both			315	141.75	36.83	318	45.58							Fee Schedule		57.66							Fee Schedule											36.83							Fee Schedule											283.5							Fee Schedule																				318							Per Diem																				
HYTINIC INJ	250	RC						Both			3.78	1.7	1.7	3.4	2.46							Fee Schedule		2.8							Fee Schedule																													3.4							Fee Schedule																																															
HYTRIN 1 MG TAB	250	RC	A9270	CPT				Both			3.91	1.76	0.01	3.52	0.01							Fee Schedule		2.89							Fee Schedule																													3.52							Fee Schedule																																															
IBUPROFEN 100 MG/5ML SUSPENSION UD	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
IBUPROFEN 200 MG CAPLET UD	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
IBUPROFEN 200 MG TABLET UD	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
IBUPROFEN 400 MG TABLET UD	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
IBUPROFEN 600 MG TABLET UD	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
IBUPROFEN 800 MG TABLET UD	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
IBUPROFEN DROPS 50MG/1.25ML CONC. 1/2 OZ	250	RC	A9270	CPT				Both			17.85	8.03	0.01	16.07	0.01							Fee Schedule		13.21							Fee Schedule																													16.07							Fee Schedule																																															
ICAST COVERED STENT 5X16MM #85440	278	RC	C1874	CPT				Both			7809	3514.05	3514.05	7028.1		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	5778.66							Fee Schedule																													7028.1							Fee Schedule																																															
ICAST COVERED STENT 6X22MM #85443	278	RC	C1874	CPT				Both			7922.25	3565.01	3565.01	7130.03		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	5862.47							Fee Schedule																													7130.03							Fee Schedule																																															
ICAST COVERED STENT 6X38MM #85412	278	RC	C1874	CPT				Both			7725	3476.25	3476.25	6952.5		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	5716.5							Fee Schedule																													6952.5							Fee Schedule																																															
ICAST COVERED STENT 8X59MM #85417	278	RC	C1874	CPT				Both			8304.45	3737	3737	7474.01		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	6145.29							Fee Schedule																													7474.01							Fee Schedule																																															
ICE PACK MATERNITY #11500-010	270	RC	A9273	CPT				Both			2	0.9	0.9	6.27	6.27							Fee Schedule		1.48							Fee Schedule																													1.8							Fee Schedule																																															
ICE PACK NON4410  MEDLINE	270	RC	A9273	CPT				Both			3	1.35	1.35	6.27	6.27							Fee Schedule		2.22							Fee Schedule																													2.7							Fee Schedule																																															
ICE PACK REFILLABLE LG #7034585	270	RC	A9273	CPT				Both			2	0.9	0.9	6.27	6.27							Fee Schedule		1.48							Fee Schedule																													1.8							Fee Schedule																																															
ICE PACK REFILLABLE SM #7034582	270	RC	A9273	CPT				Both			1	0.45	0.45	6.27	6.27							Fee Schedule		0.74							Fee Schedule																													0.9							Fee Schedule																																															
ICON 20 HCG TEST #23-280-014	270	RC						Both			11	4.95	4.95	9.9	7.15							Fee Schedule		8.14							Fee Schedule																													9.9							Fee Schedule																																															
IGA LEVEL CSF 4447	301	RC	82784	CPT				Both			54.6	24.57	8.27	49.14	8.27							Fee Schedule		10.34							Fee Schedule		9.58							Fee Schedule		9.3							Fee Schedule											49.14							Fee Schedule																				9.3							Fee Schedule																				
IGA SERUM QUEST 539	301	RC	82784	CPT				Both			21.33	9.6	8.27	19.2	8.27							Fee Schedule		10.34							Fee Schedule		9.58							Fee Schedule		9.3							Fee Schedule		9.3							Fee Schedule		19.2							Fee Schedule		10.7							Fee Schedule		8.65							Fee Schedule		9.3							Fee Schedule		10.7							Fee Schedule		8.65							Fee Schedule		
IGD LEVEL 541 SERUM	301	RC	82784	CPT				Both			85.05	38.27	8.27	76.55	8.27							Fee Schedule		10.34							Fee Schedule		9.58							Fee Schedule		9.3							Fee Schedule		9.3							Fee Schedule		76.55							Fee Schedule		10.7							Fee Schedule		8.65							Fee Schedule		9.3							Fee Schedule		10.7							Fee Schedule		8.65							Fee Schedule		
IGE ANTIBODY 18877  PLAIN RED	301	RC	83520	CPT				Both			95.46	42.96	8.65	85.91	12.43							Fee Schedule		17.27							Fee Schedule		17.79							Fee Schedule		17.27							Fee Schedule		9.3							Fee Schedule		85.91							Fee Schedule		10.7							Fee Schedule		8.65							Fee Schedule		17.27							Fee Schedule		10.7							Fee Schedule		8.65							Fee Schedule		
IGE LEVEL 542 SERUM	301	RC	82785	CPT				Both			102.9	46.31	14.63	92.61	14.63							Fee Schedule		18.29							Fee Schedule		16.95							Fee Schedule		16.46							Fee Schedule		17.27							Fee Schedule		92.61							Fee Schedule		19.86							Fee Schedule		16.06							Fee Schedule		16.46							Fee Schedule		19.86							Fee Schedule		16.06							Fee Schedule		
IGEL #1 LMA AIRWAY 820 1000	270	RC						Both			59	26.55	15.31	53.1	38.35							Fee Schedule		43.66							Fee Schedule																				16.46							Fee Schedule		53.1							Fee Schedule		18.93							Fee Schedule		15.31							Fee Schedule											18.93							Fee Schedule		15.31							Fee Schedule		
IGEL #3 LMA AIRWAY 820 3000	270	RC						Both			59	26.55	26.55	53.1	38.35							Fee Schedule		43.66							Fee Schedule																													53.1							Fee Schedule																																															
IGEL #4 LMA AIRWAY 820 4000	270	RC						Both			59	26.55	26.55	53.1	38.35							Fee Schedule		43.66							Fee Schedule																													53.1							Fee Schedule																																															
IGEL #5 LMA AIRWAY 820 5000	270	RC						Both			59	26.55	26.55	53.1	38.35							Fee Schedule		43.66							Fee Schedule																													53.1							Fee Schedule																																															
IGF BINDING PROTEIN 3 34458 1ML SERUM	301	RC	82397	CPT				Both			144.9	65.21	12.55	130.41	12.55							Fee Schedule		15.69							Fee Schedule		14.54							Fee Schedule		14.12							Fee Schedule											130.41							Fee Schedule																				14.12							Fee Schedule																				
IGF BINDING PROTEIN1 36590 1ML SERUM	301	RC	83519	CPT				Both			144.9	65.21	13.13	130.41	13.25							Fee Schedule		18.4							Fee Schedule		18.95							Fee Schedule		18.4							Fee Schedule		14.12							Fee Schedule		130.41							Fee Schedule		16.24							Fee Schedule		13.13							Fee Schedule		18.4							Fee Schedule		16.24							Fee Schedule		13.13							Fee Schedule		
IGG INDEX 4448 CSF	301	RC	82784	CPT				Both			71.4	32.13	8.27	64.26	8.27							Fee Schedule		10.34							Fee Schedule		9.58							Fee Schedule		9.3							Fee Schedule		18.4							Fee Schedule		64.26							Fee Schedule		21.16							Fee Schedule		17.11							Fee Schedule		9.3							Fee Schedule		21.16							Fee Schedule		17.11							Fee Schedule		
IGG LEVEL	301	RC	82784	CPT				Both			54.6	24.57	8.27	49.14	8.27							Fee Schedule		10.34							Fee Schedule		9.58							Fee Schedule		9.3							Fee Schedule		9.3							Fee Schedule		49.14							Fee Schedule		10.7							Fee Schedule		8.65							Fee Schedule		9.3							Fee Schedule		10.7							Fee Schedule		8.65							Fee Schedule		
IGG SERUM QUEST 543	301	RC	82784	CPT				Both			42	18.9	8.27	37.8	8.27							Fee Schedule		10.34							Fee Schedule		9.58							Fee Schedule		9.3							Fee Schedule		9.3							Fee Schedule		37.8							Fee Schedule		10.7							Fee Schedule		8.65							Fee Schedule		9.3							Fee Schedule		10.7							Fee Schedule		8.65							Fee Schedule		
IGM LEVEL CSF 4449	301	RC	82784	CPT				Both			54.6	24.57	8.27	49.14	8.27							Fee Schedule		10.34							Fee Schedule		9.58							Fee Schedule		9.3							Fee Schedule		9.3							Fee Schedule		49.14							Fee Schedule		10.7							Fee Schedule		8.65							Fee Schedule		9.3							Fee Schedule		10.7							Fee Schedule		8.65							Fee Schedule		
IGM SERUM QUEST 545	301	RC	82784	CPT				Both			21.33	9.6	8.27	19.2	8.27							Fee Schedule		10.34							Fee Schedule		9.58							Fee Schedule		9.3							Fee Schedule		9.3							Fee Schedule		19.2							Fee Schedule		10.7							Fee Schedule		8.65							Fee Schedule		9.3							Fee Schedule		10.7							Fee Schedule		8.65							Fee Schedule		
IL-2RA / CD25 SOLUBLE 34298	302	RC	83520	CPT				Both			351	157.95	8.65	315.9	12.43							Fee Schedule		17.27							Fee Schedule		17.79							Fee Schedule		17.27							Fee Schedule		9.3							Fee Schedule		315.9							Fee Schedule		10.7							Fee Schedule		8.65							Fee Schedule		17.27							Fee Schedule		10.7							Fee Schedule		8.65							Fee Schedule		
ILOSONE 125 MG PER OZ	250	RC	A9270	CPT				Both			5.63	2.53	0.01	19.86	0.01							Fee Schedule		4.17							Fee Schedule																				17.27							Fee Schedule		5.07							Fee Schedule		19.86							Fee Schedule		16.06							Fee Schedule											19.86							Fee Schedule		16.06							Fee Schedule		
IMAGER II TORQUE CATHETER C1 5FRX65CM	272	RC						Both			59	26.55	26.55	53.1	38.35							Fee Schedule		43.66							Fee Schedule																													53.1							Fee Schedule																																															
IMIPRAMINE 25MG (TOFRANIL) TABLET	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
IMIPRAMINE 887 SERUM	301	RC	80307	CPT				Both			113.4	51.03	51.03	102.06	51.72							Fee Schedule		64.65							Fee Schedule		64							Fee Schedule		62.14							Fee Schedule											102.06							Fee Schedule																				62.14							Fee Schedule																				
IMMUN ADMIN FEE EA ADDITIONAL	771	RC	90472	CPT				Both			47.25	21.26	4.57	71.46	10							Fee Schedule		34.97							Fee Schedule											4.57							Fee Schedule		62.14							Fee Schedule		42.53							Fee Schedule		71.46							Fee Schedule		57.79							Fee Schedule											71.46							Fee Schedule		57.79							Fee Schedule		
"IMMUNE ADMIN ORAL/NASAL, 1 VACC"	771	RC	90473	CPT				Both			94.5	42.53	3.13	85.05	5							Fee Schedule		69.93							Fee Schedule											3.13							Fee Schedule											85.05							Fee Schedule																																															
IMMUNE COMPLEX C3 FRAGMENTS 10781	302	RC	86332	CPT				Both			206.85	93.08	21.66	186.17	21.66							Fee Schedule		27.08							Fee Schedule		25.1							Fee Schedule		24.37							Fee Schedule											186.17							Fee Schedule																				24.37							Fee Schedule																				
"IMMUNE NASAL/ORAL, EA ADDTL VACC"	771	RC	90474	CPT				Both			47.25	21.26	3.13	42.53	5							Fee Schedule		34.97							Fee Schedule											3.13							Fee Schedule		24.37							Fee Schedule		42.53							Fee Schedule		28.03							Fee Schedule		22.66							Fee Schedule											28.03							Fee Schedule		22.66							Fee Schedule		
"IMMUNIZATION ADMIN, PROPH 1 VAC"	771	RC	90471	CPT				Both			94.5	42.53	4.47	85.05	10							Fee Schedule		69.93							Fee Schedule											4.47							Fee Schedule											85.05							Fee Schedule																																															
"IMMUNIZATION ADMIN, SHINGLES"	771	RC	90460	CPT				Both			94.5	42.53	17	85.05	17							Fee Schedule		69.93							Fee Schedule											19.18							Fee Schedule											85.05							Fee Schedule																																															
IMMUNOCYTOCHEMISTRY EACH ADDL	310	RC	88341	CPT				Both			300	135	42.04	270	42.04							Fee Schedule		58.12							Fee Schedule											56.04							Fee Schedule											270							Fee Schedule																																															
IMMUNOCYTOCHEMISTRY INITIAL SINGLE ANTIB	312	RC	88342	CPT				Both			300	135	48.01	270	48.01							Fee Schedule		64.16							Fee Schedule											63.55							Fee Schedule											270							Fee Schedule																																															
IMMUNOELECTROPHORESIS 213 URINE 10 ML	302	RC	86325	CPT				Both			115.5	51.98	19.88	103.95	19.88							Fee Schedule		24.85							Fee Schedule		23.82							Fee Schedule		23.13							Fee Schedule											103.95							Fee Schedule																				23.13							Fee Schedule																				
IMMUNOGLOBULIN G & SUBCLASSES PNL 7903	301	RC	82784	CPT				Both			30	13.5	8.27	27	8.27							Fee Schedule		10.34							Fee Schedule		9.58							Fee Schedule		9.3							Fee Schedule		23.13							Fee Schedule		27							Fee Schedule		26.6							Fee Schedule		21.51							Fee Schedule		9.3							Fee Schedule		26.6							Fee Schedule		21.51							Fee Schedule		
IMMUNOGLOBULIN G SUBCLASS 4 (5428)	301	RC	82787	CPT				Both			33	14.85	7.13	29.7	7.13							Fee Schedule		8.91							Fee Schedule		8.26							Fee Schedule		8.02							Fee Schedule		9.3							Fee Schedule		29.7							Fee Schedule		10.7							Fee Schedule		8.65							Fee Schedule											10.7							Fee Schedule		8.65							Fee Schedule		
IMODIUM AD LIQ (PER OZ)	250	RC	A9270	CPT				Both			4.88	2.2	0.01	9.22	0.01							Fee Schedule		3.61							Fee Schedule																				8.02							Fee Schedule		4.39							Fee Schedule		9.22							Fee Schedule		7.46							Fee Schedule											9.22							Fee Schedule		7.46							Fee Schedule		
IMPACT GLUTAMINE TUBE FEEDING	250	RC						Both			29.11	13.1	13.1	26.2	18.92							Fee Schedule		21.54							Fee Schedule																													26.2							Fee Schedule																																															
IMURAN:50 MG TABS	636	RC	J7500	CPT				Both			3.57	1.61	0.14	3.21		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	2.64							Fee Schedule		0.14							Fee Schedule																				3.21							Fee Schedule																																															
IN.PACT DRUG-COATED BALLOON ADM06015013P	272	RC	C2623	CPT				Both			5370	2416.5	0.13	4833	3490.5							Fee Schedule		3973.8							Fee Schedule																				0.14							Fee Schedule		4833							Fee Schedule		0.16							Fee Schedule		0.13							Fee Schedule											0.16							Fee Schedule		0.13							Fee Schedule		
IN.PACT DRUG-COATED BALLOON IPU05010013P	272	RC	C2623	CPT				Both			4920	2214	2214	4428	3198							Fee Schedule		3640.8							Fee Schedule																													4428							Fee Schedule																																															
IN.PACT DRUG-COATED BALLOON IPU05015013P	272	RC	C2623	CPT				Both			5370	2416.5	2416.5	4833	3490.5							Fee Schedule		3973.8							Fee Schedule																													4833							Fee Schedule																																															
INCENTIVE SPIROMETER #HUD8884719010	270	RC	A9284	CPT				Both			5	2.25	2.25	9.61	9.61							Fee Schedule		3.7							Fee Schedule																													4.5							Fee Schedule																																															
INCISOR 4.5 7205313   (SMITHNEPHEWENDOSC	272	RC						Both			202.65	91.19	91.19	182.39	131.72							Fee Schedule		149.96							Fee Schedule																													182.39							Fee Schedule																																															
INCISOR 4.5 BLADE  7205398	272	RC						Both			269.85	121.43	121.43	242.87	175.4							Fee Schedule		199.69							Fee Schedule																													242.87							Fee Schedule																																															
INCISOR 4.5 BLADE 3810(SMITHNEPHEWENDOSC	272	RC						Both			202.65	91.19	91.19	182.39	131.72							Fee Schedule		149.96							Fee Schedule																													182.39							Fee Schedule																																															
INCISOR 5.5 BLADE 4191(SMITHNEPHEWENDOSC	272	RC						Both			202.65	91.19	91.19	182.39	131.72							Fee Schedule		149.96							Fee Schedule																													182.39							Fee Schedule																																															
INCISOR PLUS 2.9MM #72201513	272	RC						Both			155	69.75	69.75	139.5	100.75							Fee Schedule		114.7							Fee Schedule																													139.5							Fee Schedule																																															
INCISOR PLUS 3.5MM #72201514	272	RC						Both			162.75	73.24	73.24	146.48	105.79							Fee Schedule		120.44							Fee Schedule																													146.48							Fee Schedule																																															
INCUBATOR PER DAY	170	RC						Inpatient			787.5	354.38	354.38	4562	500							Per Diem		1842							Per Diem									Other	Base Rate DRG Payment								Other	Base Rate DRG Payment								Other	DRG Base Rate	708.75							Fee Schedule									Other	DRG Base Rate								Other	DRG Base Rate	4562							Per Diem									Other	DRG Base Rate								Other	DRG Base Rate	
IND MED TREADMILL	482	RC	93017	CPT				Both			150	67.5	51.25	382	263							Per Diem		111							Fee Schedule											51.25							Fee Schedule											135							Fee Schedule																				382							Per Diem																				
INDAPAMIDE 2.5MG (LOZOL) TABLET	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
INDIGO CARMINE 0.8% 5ML VIAL	250	RC	A9270	CPT				Both			26.3	11.84	0.01	23.67	0.01							Fee Schedule		19.46							Fee Schedule																													23.67							Fee Schedule																																															
INDOCIN 50 MG R SUPP	250	RC	A9270	CPT				Both			4.57	2.06	0.01	4.11	0.01							Fee Schedule		3.38							Fee Schedule																													4.11							Fee Schedule																																															
INDOCYANINE GREEN 25MG/VIAL KIT	250	RC	C9776	CPT				Both			363.12	163.4	163.4	326.81	236.03							Fee Schedule		268.71							Fee Schedule																													326.81							Fee Schedule																																															
INDOMETHACIN 25MG (INDOCIN) CAPSULE	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
INDOMETHACIN RECTAL SUPPOSITORY 50MG	636	RC	J7999	CPT				Both			1237.71	556.97	556.97	1113.94		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	915.91							Fee Schedule																													1113.94							Fee Schedule																																															
INDUSTRIAL CADMIUM SCREEN 8887	301	RC	82300	CPT				Both			126	56.7	20.58	113.4	20.58							Fee Schedule		25.72							Fee Schedule		24.35							Fee Schedule		23.64							Fee Schedule											113.4							Fee Schedule																				23.64							Fee Schedule																				
INDUSTRIAL MED-HEP B ADMIN FEE	771	RC	90471	CPT				Both			94.5	42.53	4.47	85.05	10							Fee Schedule		69.93							Fee Schedule											4.47							Fee Schedule		23.64							Fee Schedule		85.05							Fee Schedule		27.19							Fee Schedule		21.99							Fee Schedule											27.19							Fee Schedule		21.99							Fee Schedule		
INFANRIX (DTaP)  VACCINE <7YRS	636	RC	90700	CPT				Both			50.4	22.68	22.68	45.36		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	37.3							Fee Schedule											32.47							Fee Schedule											45.36							Fee Schedule																																															
INFANRIX 0.5ML INJECTION (SYRINGE)	250	RC						Both			82.38	37.07	37.07	74.14	53.55							Fee Schedule		60.96							Fee Schedule																													74.14							Fee Schedule																																															
INFANT AMBU BAG 10-55284 (MERCURY)	271	RC						Both			116.03	52.21	52.21	104.43	75.42							Fee Schedule		85.86							Fee Schedule																													104.43							Fee Schedule																																															
INFANT CPR-2 AMBU BAG 10-56242	270	RC						Both			58	26.1	26.1	52.2	37.7							Fee Schedule		42.92							Fee Schedule																													52.2							Fee Schedule																																															
INFANT MASK VITAL SIGN #6820	271	RC						Both			7	3.15	3.15	6.3	4.55							Fee Schedule		5.18							Fee Schedule																													6.3							Fee Schedule																																															
INFANT TRANS-WARMING MATTRESS #7034551	271	RC						Both			29	13.05	13.05	26.1	18.85							Fee Schedule		21.46							Fee Schedule																													26.1							Fee Schedule																																															
INFECTIOUS AGENT ANTIGEN DETECTION	310	RC	87494	CPT				Both			115.5	51.98	51.98	103.95	75.08							Fee Schedule		70.18							Fee Schedule		72.29							Fee Schedule		70.18							Fee Schedule											103.95							Fee Schedule																																															
INFECTIOUS AGENT DETECTION 16/18 ONLY	306	RC	87625	CPT				Both			157.5	70.88	31.2	141.75	31.2							Fee Schedule		40.55							Fee Schedule		41.77							Fee Schedule		40.55							Fee Schedule		70.18							Fee Schedule		141.75							Fee Schedule		80.71							Fee Schedule		65.27							Fee Schedule		40.55							Fee Schedule		80.71							Fee Schedule		65.27							Fee Schedule		
INFECTIOUS AGENT DNA/RNA	306	RC	87624	CPT				Both			157.5	70.88	31.2	141.75	31.2							Fee Schedule		38.99							Fee Schedule		36.14							Fee Schedule		35.09							Fee Schedule		40.55							Fee Schedule		141.75							Fee Schedule		46.63							Fee Schedule		37.71							Fee Schedule		35.09							Fee Schedule		46.63							Fee Schedule		37.71							Fee Schedule		
INFLAMMATORY BOWEL DISEASE WITH MCC					385	DRG		Inpatient			63245.02	28460.26	28460.26	28460.26							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0	Fee Schedule	No services provided during 15 month lookback period				6263.72	6263.72	6263.72	1 through 10	Fee Schedule								0		No services provided during 15 month lookback							0		No services provided during 15 month lookback period							0	Fee Schedule	No services provided during 15 month lookback period	
INFLAMMATORY BOWEL DISEASE WITH CC					386	DRG		Inpatient			13462.25	6058.01	6058.01	6058.01							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period	
INFED 100MG/ 2ML  INJECTION	636	RC	J1750	CPT				Both			134.22	60.4	18.1	120.8		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	18.1							Fee Schedule		18.62							Fee Schedule																				120.8							Fee Schedule																																															
INFED 25MG/NS 100ML-TEST DOSE	636	RC	J1750	CPT				Both			134.22	60.4	16.82	120.8		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	18.1							Fee Schedule		18.62							Fee Schedule											18.08							Fee Schedule		120.8							Fee Schedule		20.79							Fee Schedule		16.82							Fee Schedule											20.79							Fee Schedule		16.82							Fee Schedule		
INFED 975MG/NS 250ML IVPB	636	RC	J1750	CPT				Both			1342.2	603.99	16.82	1207.98		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	18.1							Fee Schedule		18.62							Fee Schedule											18.08							Fee Schedule		1207.98							Fee Schedule		20.79							Fee Schedule		16.82							Fee Schedule											20.79							Fee Schedule		16.82							Fee Schedule		
INFLAMMATORY BOWEL DISEASE WITHOUT CC/MCC					387	DRG		Inpatient			21797.85	9809.03	9809.03	9809.03							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0	Fee Schedule	No services provided during 15 month lookback period							0	Fee Schedule	No services provided during 15 month lookback period							0		No services provided during 15 month lookback							0		No services provided during 15 month lookback period							0	Fee Schedule	No services provided during 15 month lookback period	
GASTROINTESTINAL OBSTRUCTION WITH MCC					388	DRG		Inpatient			53908.82	24258.97	24258.97	24258.97							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period. 				11517.18	11517.18	11517.18	1 through 10									0		No services provided during 15 month lookback period				4571.04	4571.04	4571.04	1 through 10									0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period	
GASTROINTESTINAL OBSTRUCTION WITH CC					389	DRG		Inpatient			37046.51	16670.93	16670.93	16670.93							0		No services performed during 15 month lookback period. 				14038.2	14038.2	14038.2	1 through 10						8140.6	8140.6	8140.6	1 through 10									0		No services provided during 15 month lookback period				3425.67	3425.67	3425.67	1 through 10									0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback				7453.19	7453.19	7453.19	1 through 10									0		No services provided during 15 month lookback period	
GASTROINTESTINAL OBSTRUCTION WITHOUT CC/MCC					390	DRG		Inpatient			22148.6	9966.87	9966.87	9966.87							0		No services performed during 15 month lookback period. 				3222.87	3222.87	3222.87	1 through 10									0		No services performed during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback				4964.56	4964.56	4964.56	1 through 10									0		No services provided during 15 month lookback period	
INFLATABLE PENILE PROSTHESIS 72404234-14	278	RC	C1813	CPT				Both			44310	19939.5	19939.5	39879		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	32789.4							Fee Schedule																													39879							Fee Schedule																																															
INFLECTRA INTRAVENOUS PWD FOR SOLN 100MG	636	RC	Q5103	CPT				Both			3406.62	1532.98	24.95	3065.96		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	25.56							Fee Schedule		24.95							Fee Schedule																				3065.96							Fee Schedule																																															
INFLIXIMAB  AB 36301 1 ML SERUM REFRIG	300	RC	86255	CPT				Both			393.75	177.19	10.71	354.38	10.71							Fee Schedule		13.39							Fee Schedule		12.41							Fee Schedule		12.05							Fee Schedule		24.22							Fee Schedule		354.38							Fee Schedule		27.85							Fee Schedule		22.52							Fee Schedule		12.05							Fee Schedule		27.85							Fee Schedule		22.52							Fee Schedule		
INFLIXIMAB 100MG (REMICADE)	636	RC	J1745	CPT				Both			1710	769.5	11.21	1539		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	31.04							Fee Schedule		33.4							Fee Schedule											12.05							Fee Schedule		1539							Fee Schedule		13.86							Fee Schedule		11.21							Fee Schedule											13.86							Fee Schedule		11.21							Fee Schedule		
INFLUENZA  A  B ANTIGENS SWT LAB	306	RC	87400	CPT				Both			68.25	30.71	10.66	61.43	10.66							Fee Schedule		14.13							Fee Schedule		14.55							Fee Schedule		14.13							Fee Schedule		32.42							Fee Schedule		61.43							Fee Schedule		37.29							Fee Schedule		30.15							Fee Schedule		14.13							Fee Schedule		37.29							Fee Schedule		30.15							Fee Schedule		
INFLUENZA  A & B ANTIGENS SOFIA	306	RC	87400	CPT				Both			68.25	30.71	10.66	61.43	10.66							Fee Schedule		14.13							Fee Schedule		14.55							Fee Schedule		14.13							Fee Schedule		14.13							Fee Schedule		61.43							Fee Schedule		16.25							Fee Schedule		13.14							Fee Schedule		14.13							Fee Schedule		16.25							Fee Schedule		13.14							Fee Schedule		
INFLUENZA A  B ANTIGENS 8357 REF LAB	302	RC	86710	CPT				Both			65.1	29.3	12.05	58.59	12.05							Fee Schedule		15.06							Fee Schedule		13.96							Fee Schedule		13.55							Fee Schedule		14.13							Fee Schedule		58.59							Fee Schedule		16.25							Fee Schedule		13.14							Fee Schedule		13.55							Fee Schedule		16.25							Fee Schedule		13.14							Fee Schedule		
INFLUENZA TYPES A/B ABS 7250	302	RC	86256	CPT				Both			325.5	146.48	10.71	292.95	10.71							Fee Schedule		13.39							Fee Schedule		12.41							Fee Schedule		12.05							Fee Schedule		13.55							Fee Schedule		292.95							Fee Schedule		15.58							Fee Schedule		12.6							Fee Schedule		12.05							Fee Schedule		15.58							Fee Schedule		12.6							Fee Schedule		
INFRAVISION ESOPHAGEAL KIT(STRYKER-ENDOS	272	RC						Both			786.45	353.9	11.21	707.81	511.19							Fee Schedule		581.97							Fee Schedule																				12.05							Fee Schedule		707.81							Fee Schedule		13.86							Fee Schedule		11.21							Fee Schedule											13.86							Fee Schedule		11.21							Fee Schedule		
INFUSE KIT SMALL #7510200 (FIRST CHOICE	278	RC	C1762	CPT				Both			12358.5	5561.33	5561.33	11122.65		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	9145.29							Fee Schedule																													11122.65							Fee Schedule																																															
INFUSER 1000CC #DYNJAAPI1000S (MEDLINE)	271	RC						Both			48	21.6	21.6	43.2	31.2							Fee Schedule		35.52							Fee Schedule																													43.2							Fee Schedule																																															
INFUSER 3000CC #DYNJAAPI300SH (MEDLINE)	271	RC						Both			32	14.4	14.4	28.8	20.8							Fee Schedule		23.68							Fee Schedule																													28.8							Fee Schedule																																															
INFUSER 500CC #DYNJAAPI500S (MEDLINE)	271	RC						Both			30	13.5	13.5	27	19.5							Fee Schedule		22.2							Fee Schedule																													27							Fee Schedule																																															
INHIBIN A 34472 2ML SERUM RT	302	RC	86336	CPT				Both			84	37.8	13.85	75.6	13.85							Fee Schedule		17.32							Fee Schedule		16.06							Fee Schedule		15.59							Fee Schedule											75.6							Fee Schedule																				15.59							Fee Schedule																				
INHIBIN B 34445 1ML SERUM RT	300	RC	82397	CPT				Both			49.35	22.21	12.55	44.42	12.55							Fee Schedule		15.69							Fee Schedule		14.54							Fee Schedule		14.12							Fee Schedule		15.59							Fee Schedule		44.42							Fee Schedule		17.93							Fee Schedule		14.5							Fee Schedule		14.12							Fee Schedule		17.93							Fee Schedule		14.5							Fee Schedule		
INJ FEE THERAPY  PROPH DIAGN SUBQ IM	260	RC	96372	CPT				Both			88	39.6	13.13	79.2	18.9							Fee Schedule		65.12							Fee Schedule											16.71							Fee Schedule		14.12							Fee Schedule		79.2							Fee Schedule		16.24							Fee Schedule		13.13							Fee Schedule											16.24							Fee Schedule		13.13							Fee Schedule		
INJ MAMMARY DUCTOGRAM OR GALACTOGRAM	320	RC	19030	CPT				Both			525	236.25	84.98	472.5	84.98							Fee Schedule		388.5							Fee Schedule																													472.5							Fee Schedule																				318							Per Diem																				
"INJ THERAP, PROPH, DIAGN ADD HR"	260	RC	96366	CPT				Both			84	37.8	17.31	75.6	20.2							Fee Schedule		62.16							Fee Schedule											17.31							Fee Schedule											75.6							Fee Schedule																																															
"INJ THERAP, PROPH, DIAGN INIT HR"	260	RC	96365	CPT				Both			306	137.7	53.47	275.4	65.69							Fee Schedule		226.44							Fee Schedule											53.47							Fee Schedule											275.4							Fee Schedule																																															
INJECTAFER 750MG/15ML INJECTION	636	RC	J1439	CPT				Both			3472.35	1562.56	1.1	3125.12		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1.1							Fee Schedule		1.15							Fee Schedule																				3125.12							Fee Schedule																																															
INJECTAFER 750MG/15ML INJECTION	636	RC	J1439	CPT				Both			5205.21	2342.34	1.04	4684.69		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1.1							Fee Schedule		1.15							Fee Schedule											1.12							Fee Schedule		4684.69							Fee Schedule		1.28							Fee Schedule		1.04							Fee Schedule											1.28							Fee Schedule		1.04							Fee Schedule		
INJECTAFER 750MG/NS 250ML IVPB	636	RC	J1439	CPT				Both			4954.5	2229.53	1.04	4459.05		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1.1							Fee Schedule		1.15							Fee Schedule											1.12							Fee Schedule		4459.05							Fee Schedule		1.28							Fee Schedule		1.04							Fee Schedule											1.28							Fee Schedule		1.04							Fee Schedule		
INJECTION- ANTIBIOTIC PER VISIT (DAY)	260	RC	96372	CPT				Both			84	37.8	1.04	75.6	18.9							Fee Schedule		62.16							Fee Schedule											16.71							Fee Schedule		1.12							Fee Schedule		75.6							Fee Schedule		1.28							Fee Schedule		1.04							Fee Schedule											1.28							Fee Schedule		1.04							Fee Schedule		
INJECTION- IA PER VISIT (DAY)	260	RC	96373	CPT				Both			126	56.7	14.38	113.4	17.63							Fee Schedule		93.24							Fee Schedule											14.38							Fee Schedule											113.4							Fee Schedule																																															
INJECTION LUMBAR EPIDURAL OF BLOOD CLOT	370	RC	62272	CPT				Both			202.65	91.19	91.19	182.39	105.16							Fee Schedule		149.96							Fee Schedule																													182.39							Fee Schedule																																															
INJECTION LUMBAR EPIDURAL OF BLOOD CLOT			62273	CPT				Both			202.65	91.19	91.19	182.39	147.41							Fee Schedule		149.96							Fee Schedule																													182.39							Fee Schedule																																															
INJECTION LUMBAR EPIDURAL OF BLOOD CLOT	370	RC	62272	CPT				Both			202.65	91.19	91.19	182.39	105.16							Fee Schedule		149.96							Fee Schedule																													182.39							Fee Schedule																																															
INJECTION-IM SUBQ-EACH INJECTION	260	RC	96372	CPT				Both			88	39.6	16.71	79.2	18.9							Fee Schedule		65.12							Fee Schedule											16.71							Fee Schedule											79.2							Fee Schedule																																															
INJETAK CYSTOSCOPY NEEDLE 70CM DIS201	272	RC						Both			296	133.2	133.2	266.4	192.4							Fee Schedule		219.04							Fee Schedule																													266.4							Fee Schedule																																															
INODOFORM GAUZE 1	272	RC						Both			13.65	6.14	6.14	12.29	8.87							Fee Schedule		10.1							Fee Schedule																													12.29							Fee Schedule																																															
INOMED MICRO FORK PROBE 5140-522-610	272	RC						Both			360	162	162	324	234							Fee Schedule		266.4							Fee Schedule																													324							Fee Schedule																																															
INOMED NEEDLE ELECTRODE 5140-533-625	272	RC						Both			90	40.5	40.5	81	58.5							Fee Schedule		66.6							Fee Schedule																													81							Fee Schedule																																															
INOMED SUBDERMAL ELECTR. BU 5140-534-626	272	RC						Both			105	47.25	47.25	94.5	68.25							Fee Schedule		77.7							Fee Schedule																													94.5							Fee Schedule																																															
INOMED SUBDERMAL ELECTR. RD 5140-534-625	272	RC						Both			105	47.25	47.25	94.5	68.25							Fee Schedule		77.7							Fee Schedule																													94.5							Fee Schedule																																															
INS GLARGINE (LANTUS) 100 UNITS/ML-10ML	250	RC	J1815	CPT				Both			1071	481.95	0.9	963.9	0.9							Fee Schedule		792.54							Fee Schedule																													963.9							Fee Schedule																																															
INS GLARGINE 100 UNITS/ML-10ML-ER ONLY	250	RC	J1815	CPT				Both			1	0.45	0.45	0.9	0.9							Fee Schedule		0.74							Fee Schedule																													0.9							Fee Schedule																																															
INS HUMALOG 100 UNIT/ML-10ML-ER &CLINICS	250	RC	J1815	CPT				Both			2.39	1.08	0.9	2.15	0.9							Fee Schedule		1.77							Fee Schedule																													2.15							Fee Schedule																																															
INS HUMALOG MIXTURE 50/50 PEN	250	RC	J1815	CPT				Both			561.58	252.71	0.9	505.42	0.9							Fee Schedule		415.57							Fee Schedule																													505.42							Fee Schedule																																															
INS HUMALOG MIXTURE 75/25 INJECTION	250	RC	J1815	CPT				Both			413.5	186.08	0.9	372.15	0.9							Fee Schedule		305.99							Fee Schedule																													372.15							Fee Schedule																																															
INS HUMALOG MIXTURE 75/25 PEN INJ	250	RC	J1815	CPT				Both			55.23	24.85	0.9	49.71	0.9							Fee Schedule		40.87							Fee Schedule																													49.71							Fee Schedule																																															
INS HUMULIN 50/50 INJ	250	RC	J1815	CPT				Both			5.25	2.36	0.9	4.73	0.9							Fee Schedule		3.89							Fee Schedule																													4.73							Fee Schedule																																															
INS HUMULIN 70/30 100UNITS/ML  3ML VIAL	250	RC	J1815	CPT				Both			73.93	33.27	0.9	66.54	0.9							Fee Schedule		54.71							Fee Schedule																													66.54							Fee Schedule																																															
INS HUMULIN 70/30 INJ	250	RC	J1815	CPT				Both			11.55	5.2	0.9	10.4	0.9							Fee Schedule		8.55							Fee Schedule																													10.4							Fee Schedule																																															
INS HUMULIN LENTE INJ	250	RC	J1815	CPT				Both			11.55	5.2	0.9	10.4	0.9							Fee Schedule		8.55							Fee Schedule																													10.4							Fee Schedule																																															
INS HUMULIN N-100 INJ	250	RC	J1815	CPT				Both			156.21	70.29	0.9	140.59	0.9							Fee Schedule		115.6							Fee Schedule																													140.59							Fee Schedule																																															
INS HUMULIN R PER UNIT	250	RC	J1815	CPT				Both			1.05	0.47	0.47	0.95	0.9							Fee Schedule		0.78							Fee Schedule																													0.95							Fee Schedule																																															
INS HUMULIN R-100 INJECTION MDV	250	RC	J1815	CPT				Both			11.55	5.2	0.9	10.4	0.9							Fee Schedule		8.55							Fee Schedule																													10.4							Fee Schedule																																															
INS HUMULIN R-100 UNITS/ML 10ML PER UNIT	250	RC	J1815	CPT				Both			1.05	0.47	0.47	0.95	0.9							Fee Schedule		0.78							Fee Schedule																													0.95							Fee Schedule																																															
INS HUMULIN R-100 UNITS/ML 3 ML PER UNIT	250	RC	J1815	CPT				Both			1.05	0.47	0.47	0.95	0.9							Fee Schedule		0.78							Fee Schedule																													0.95							Fee Schedule																																															
INS HUMULIN R-100 UNITS/NS 100 ML IVPB	250	RC	J1817	CPT				Both			132.3	59.54	3.15	119.07	10.78							Fee Schedule		97.9							Fee Schedule		3.15							Fee Schedule																				119.07							Fee Schedule																																															
INS HUMULIN R-100 UNITS/NS 100 ML PREMIX	250	RC	J1815	CPT				Both			132.3	59.54	0.9	119.07	0.9							Fee Schedule		97.9							Fee Schedule																				3.06							Fee Schedule		119.07							Fee Schedule		3.52							Fee Schedule		2.85							Fee Schedule											3.52							Fee Schedule		2.85							Fee Schedule		
INS HUMULIN U INJ   (DNU)	250	RC	J1815	CPT				Both			10.5	4.73	0.9	9.45	0.9							Fee Schedule		7.77							Fee Schedule																													9.45							Fee Schedule																																															
INS HUMULIN-N 100 UNITS/ML 10ML	250	RC	J1815	CPT				Both			160.59	72.27	0.9	144.53	0.9							Fee Schedule		118.84							Fee Schedule																													144.53							Fee Schedule																																															
INS LANTUS 100 UNITS/ML-10 ML	250	RC	J1815	CPT				Both			231.33	104.1	0.9	208.2	0.9							Fee Schedule		171.18							Fee Schedule																													208.2							Fee Schedule																																															
INS LEVEMIR 100 UNITS/ML	250	RC	J1815	CPT				Both			630	283.5	0.9	567	0.9							Fee Schedule		466.2							Fee Schedule																													567							Fee Schedule																																															
INS LISPRO (ADMELOG) 100UNIT/ML-3ML VIAL	250	RC	J1815	CPT				Both			141.24	63.56	0.9	127.12	0.9							Fee Schedule		104.52							Fee Schedule																													127.12							Fee Schedule																																															
INS NOVOLIN 70/30	250	RC	J1815	CPT				Both			143.58	64.61	0.9	129.22	0.9							Fee Schedule		106.25							Fee Schedule																													129.22							Fee Schedule																																															
INS NOVOLIN R-100 UNITS/ML-10ML-ER ONLY	250	RC	J1815	CPT				Both			1	0.45	0.45	0.9	0.9							Fee Schedule		0.74							Fee Schedule																													0.9							Fee Schedule																																															
INS NOVOLIN R-100 UNITS/NS 100 ML IVPB	250	RC	J1815	CPT				Both			132.3	59.54	0.9	119.07	0.9							Fee Schedule		97.9							Fee Schedule																													119.07							Fee Schedule																																															
INS NOVOLIN-L 100 UNITS/ML INJECTION	250	RC	J1815	CPT				Both			10.5	4.73	0.9	9.45	0.9							Fee Schedule		7.77							Fee Schedule																													9.45							Fee Schedule																																															
INS NOVOLIN-N 100 UNITS/ML INJECTION	250	RC	A9270	CPT				Both			208.28	93.73	0.01	187.45	0.01							Fee Schedule		154.13							Fee Schedule																													187.45							Fee Schedule																																															
INS NOVOLOG 100 UNITS/ML INJECTION	250	RC	A9270	CPT				Both			448.69	201.91	0.01	403.82	0.01							Fee Schedule		332.03							Fee Schedule																													403.82							Fee Schedule																																															
INS NOVOLOG MIXTURE 70/30 INJECTION	250	RC	A9270	CPT				Both			448.69	201.91	0.01	403.82	0.01							Fee Schedule		332.03							Fee Schedule																													403.82							Fee Schedule																																															
INSERTION CENTRAL VENOUS			36556	CPT				Both			420	189	152.48	378	152.48							Fee Schedule		310.8							Fee Schedule																													378							Fee Schedule																																															
INSORB SKIN STAPLER ABSORBABLE #2030	272	RC						Both			247	111.15	111.15	222.3	160.55							Fee Schedule		182.78							Fee Schedule																													222.3							Fee Schedule																																															
INSPIRE IMPLANT. PULSE GENERATOR V 3150	278	RC	C1767	CPT				Both			64800	29160	29160	58320		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	47952							Fee Schedule																													58320							Fee Schedule																																															
INSPIRE RESPIRATORY SENSING LEAD 4340	278	RC	C1778	CPT				Both			10125	4556.25	4556.25	9112.5		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	7492.5							Fee Schedule																													9112.5							Fee Schedule																																															
INSPIRE SLEEP REMOTE CONTROL 2580	270	RC	C1787	CPT				Both			4200	1890	35.29	3780	35.29							Fee Schedule		3108							Fee Schedule																													3780							Fee Schedule																																															
INSPIRE STIMULATION LEAD 4063	278	RC	C1778	CPT				Both			5850	2632.5	2632.5	5265		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	4329							Fee Schedule																													5265							Fee Schedule																																															
INSPIREASE INHALER	250	RC	A9270	CPT				Both			48.3	21.74	0.01	43.47	0.01							Fee Schedule		35.74							Fee Schedule																													43.47							Fee Schedule																																															
INSULIN 561 SERUM 1ML FROZEN	301	RC	83525	CPT				Both			63	28.35	10.16	56.7	10.16							Fee Schedule		12.7							Fee Schedule		11.77							Fee Schedule		11.43							Fee Schedule											56.7							Fee Schedule																				11.43							Fee Schedule																				
INSULIN ANTIBODIES 36178 SERUM	302	RC	86337	CPT				Both			954	429.3	10.63	858.6	19.03							Fee Schedule		23.79							Fee Schedule		22.05							Fee Schedule		21.41							Fee Schedule		11.43							Fee Schedule		858.6							Fee Schedule		13.14							Fee Schedule		10.63							Fee Schedule		21.41							Fee Schedule		13.14							Fee Schedule		10.63							Fee Schedule		
INSULIN LIKE GROWTH FACTOR  839 IGF1	301	RC	84305	CPT				Both			110.25	49.61	18.9	99.23	18.9							Fee Schedule		23.63							Fee Schedule		21.9							Fee Schedule		21.26							Fee Schedule		21.41							Fee Schedule		99.23							Fee Schedule		24.62							Fee Schedule		19.91							Fee Schedule		21.26							Fee Schedule		24.62							Fee Schedule		19.91							Fee Schedule		
INSULIN PER ER	250	RC	A9270	CPT				Both			45.15	20.32	0.01	40.64	0.01							Fee Schedule		33.41							Fee Schedule																				21.26							Fee Schedule		40.64							Fee Schedule		24.45							Fee Schedule		19.77							Fee Schedule											24.45							Fee Schedule		19.77							Fee Schedule		
INSULIN PER ER	250	RC	A9270	CPT				Both			45.15	20.32	0.01	40.64	0.01							Fee Schedule		33.41							Fee Schedule																													40.64							Fee Schedule																																															
INSULIN-LIKE GROWTH FACTOR 16293	301	RC	84305	CPT				Both			191.1	86	18.9	171.99	18.9							Fee Schedule		23.63							Fee Schedule		21.9							Fee Schedule		21.26							Fee Schedule											171.99							Fee Schedule																				21.26							Fee Schedule																				
INT	272	RC						Both			84	37.8	19.77	75.6	54.6							Fee Schedule		62.16							Fee Schedule																				21.26							Fee Schedule		75.6							Fee Schedule		24.45							Fee Schedule		19.77							Fee Schedule											24.45							Fee Schedule		19.77							Fee Schedule		
INT (SALINE FLUSHES)	272	RC	A4216	CPT				Both			12.6	5.67	0.34	11.34	0.34							Fee Schedule		9.32							Fee Schedule		0.56							Fee Schedule																				11.34							Fee Schedule																																															
INT CENTRAL LINE PER 10 UNITS 100UNIT VL	636	RC	J1642	CPT				Both			5.25	2.36	0.02	4.73		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	3.89							Fee Schedule		0.02							Fee Schedule		0.68							Fee Schedule		0.54							Fee Schedule		4.73							Fee Schedule		0.62							Fee Schedule		0.5							Fee Schedule											0.62							Fee Schedule		0.5							Fee Schedule		
INTEGRILIN 0.75MG/ML INJECTION	636	RC	J3246	CPT				Both			1024.89	461.2	0.02	922.4		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	758.42							Fee Schedule		3							Fee Schedule											0.02							Fee Schedule		922.4							Fee Schedule		0.02							Fee Schedule		0.02							Fee Schedule											0.02							Fee Schedule		0.02							Fee Schedule		
INTEGRILIN 2MG/ML INJECTION	636	RC	J3246	CPT				Both			2224.65	1001.09	2.71	2002.19		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1646.24							Fee Schedule		3							Fee Schedule											2.92							Fee Schedule		2002.19							Fee Schedule		3.35							Fee Schedule		2.71							Fee Schedule											3.35							Fee Schedule		2.71							Fee Schedule		
INTERCEED 4350	278	RC	C1765	CPT				Both			1492	671.4	2.71	1342.8		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1104.08							Fee Schedule																				2.92							Fee Schedule		1342.8							Fee Schedule		3.35							Fee Schedule		2.71							Fee Schedule											3.35							Fee Schedule		2.71							Fee Schedule		
INTERFERENCE SCREW ARTHROTEK	278	RC	C1713	CPT				Both			362.25	163.01	163.01	326.03		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	268.07							Fee Schedule																													326.03							Fee Schedule																																															
INTERFERON ALFA 3 M/IUNITS INJECTION	636	RC	J9213	CPT				Both			110.03	49.51	49.51	99.03		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	81.42							Fee Schedule																													99.03							Fee Schedule																																															
INTERJECT CONTRAST NEEDLE #M00518361	272	RC						Both			95	42.75	42.75	85.5	61.75							Fee Schedule		70.3							Fee Schedule																													85.5							Fee Schedule																																															
"INTERLEUKIN-6 (IL-6), 34473 SERUM"	302	RC	83529	CPT				Both			351	157.95	17.27	315.9	228.15							Fee Schedule		17.27							Fee Schedule		17.79							Fee Schedule		17.27							Fee Schedule											315.9							Fee Schedule																				17.27							Fee Schedule																				
INTERSTIM X # 97800 MEDTRONIC	278	RC	L8686	CPT				Both			33348	15006.6	16.06	30013.2		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	24677.52							Fee Schedule																				17.27							Fee Schedule		30013.2							Fee Schedule		19.86							Fee Schedule		16.06							Fee Schedule											19.86							Fee Schedule		16.06							Fee Schedule		
INTERSTIM X HANDSET #TH90Q01 MEDTRONIC	272	RC	L8681	CPT				Both			5061	2277.45	577	4554.9	577							Fee Schedule		3745.14							Fee Schedule		1440.28							Fee Schedule																				4554.9							Fee Schedule																																															
INTERSTIM X LEAD 28CM # 978B128 MEDTRONI	278	RC	L8680	CPT				Both			11820	5319	1300.45	10638		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	8746.8							Fee Schedule																				1398.33							Fee Schedule		10638							Fee Schedule		1608.08							Fee Schedule		1300.45							Fee Schedule											1608.08							Fee Schedule		1300.45							Fee Schedule		
INTERSTIM X TEST STIMULATOR # 353101 MED	272	RC						Both			1038	467.1	467.1	934.2	674.7							Fee Schedule		768.12							Fee Schedule																													934.2							Fee Schedule																																															
"ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DIS"					391	DRG		Inpatient			36561.7	16452.76	16452.76	16452.76							0		No services performed during 15 month lookback period. 				4592.54	4592.54	4592.54	1 through 10									0		No services performed during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback				10073.99	10073.99	10073.99	1 through 10									0		No services provided during 15 month lookback period	
"ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DIS"					392	DRG		Inpatient			27213.23	12245.95	12245.95	12245.95							0		No services performed during 15 month lookback period. 				3973.32	535.44	13284.06	15									0		No services performed during 15 month lookback period				3520.1	3520.1	3520.1	1 through 10						3157.59	3157.59	3157.59	1 through 10									0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period				3045.8	3045.8	3045.8	1 through 10						9416.86	9416.86	9416.86	1 through 10									0		No services provided during 15 month lookback period				3726.14	3726.14	3726.14	1 through 10			
OTHER DIGESTIVE SYSTEM DIAGNOSES WITH MCC					393	DRG		Inpatient			47619.48	21428.77	21428.77	21428.77							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period	
OTHER DIGESTIVE SYSTEM DIAGNOSES WITH CC					394	DRG		Inpatient			27762.12	12492.95	12492.95	12492.95							0		No services performed during 15 month lookback period. 				9995.64	9995.64	9995.64	1 through 10									0		No services performed during 15 month lookback period				4390.23	4390.23	4390.23	1 through 10						5371.71	5371.71	5371.71	1 through 10									0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period	
INTRALIPID 20% 250ML BIOF 2B6063 ( 340B)	258	RC	B4185	CPT				Both			39	17.55	7.22	35.1	7.22							Fee Schedule		28.86							Fee Schedule																													35.1							Fee Schedule																																															
INTRALIPID 20% 500ML CLINOLIPID ( 340B )	270	RC	B4185	CPT				Both			23	10.35	7.22	20.7	7.22							Fee Schedule		17.02							Fee Schedule																													20.7							Fee Schedule																																															
INTRAOS NEEDLE 25MM 9001-VC-005 TELEFLEX	272	RC	A0394	CPT				Both			410	184.5	17.19	369	17.19							Fee Schedule		303.4							Fee Schedule																													369							Fee Schedule																																															
INTRAOS STABILIZER 9066-VC-005 TELEFLEX	272	RC						Both			54	24.3	24.3	48.6	35.1							Fee Schedule		39.96							Fee Schedule																													48.6							Fee Schedule																																															
INTRAOS. NEEDLE 15MM #9018V ( VIDACARE	272	RC						Both			430.5	193.73	193.73	387.45	279.83							Fee Schedule		318.57							Fee Schedule																													387.45							Fee Schedule																																															
INTRAOS. NEEDLE 45MM #9079-VC(TELEFLEX)	272	RC	A0394	CPT				Both			410	184.5	17.19	369	17.19							Fee Schedule		303.4							Fee Schedule																													369							Fee Schedule																																															
INTRAOSS. 15MM NEEDLE SET #9018P-VC-005	272	RC						Both			449.4	202.23	202.23	404.46	292.11							Fee Schedule		332.56							Fee Schedule																													404.46							Fee Schedule																																															
INTRAOSSEOUS NEEDLE C-DIN-18-3.0-T45	272	RC						Both			163.8	73.71	73.71	147.42	106.47							Fee Schedule		121.21							Fee Schedule																													147.42							Fee Schedule																																															
INTRARTERIAL INFUSION	260	RC	96373	CPT				Both			126	56.7	14.38	113.4	17.63							Fee Schedule		93.24							Fee Schedule											14.38							Fee Schedule											113.4							Fee Schedule																																															
INTRINSIC FACTOR AB  568  SERUM 1ML FRZ	302	RC	86340	CPT				Both			127.05	57.17	13.4	114.35	13.4							Fee Schedule		16.75							Fee Schedule		15.53							Fee Schedule		15.08							Fee Schedule											114.35							Fee Schedule																				15.08							Fee Schedule																				
INTRODUCER PEEL AWAY 8 FR.(ST. JUDE)	272	RC						Both			166.95	75.13	14.02	150.26	108.52							Fee Schedule		123.54							Fee Schedule																				15.08							Fee Schedule		150.26							Fee Schedule		17.34							Fee Schedule		14.02							Fee Schedule											17.34							Fee Schedule		14.02							Fee Schedule		
INTRODUCER SUPER SHEATH XL 12FR 15-718B	272	RC	C1894	CPT				Both			33	14.85	14.85	87.34	87.34							Fee Schedule		24.42							Fee Schedule																													29.7							Fee Schedule																																															
INTRODUCER SUPER SHEATH XL 15-728B	278	RC	C1894	CPT				Both			34.65	15.59	15.59	31.19		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	25.64							Fee Schedule																													31.19							Fee Schedule																																															
INTRODUCER TRAY 8.5 SAFETY #SI500BF85I	272	RC						Both			225	101.25	101.25	202.5	146.25							Fee Schedule		166.5							Fee Schedule																													202.5							Fee Schedule																																															
"INTUBATION,ENDOTRACHEAL EMER PROCD CLOT"			31500	CPT				Both			202.65	91.19	91.19	204.76	204.76							Fee Schedule		149.96							Fee Schedule																													182.39							Fee Schedule																																															
INTUIT 8MM FORCE BIPOLA 471405 (12 USES)	270	RC						Both			741	333.45	333.45	666.9	481.65							Fee Schedule		548.34							Fee Schedule																													666.9							Fee Schedule																																															
INTUIT BIPOLAR CAU CORD 470383 (20 USES)	270	RC						Both			43	19.35	19.35	38.7	27.95							Fee Schedule		31.82							Fee Schedule																													38.7							Fee Schedule																																															
INTUIT BIPOLAR CAU CORD 470384 (20 USES)	270	RC						Both			43	19.35	19.35	38.7	27.95							Fee Schedule		31.82							Fee Schedule																													38.7							Fee Schedule																																															
INTUIT CADIERE FORCEPS 471049 (18 USES)	270	RC						Both			473	212.85	212.85	425.7	307.45							Fee Schedule		350.02							Fee Schedule																													425.7							Fee Schedule																																															
INTUIT FEN BIP FORCEPS 471205 (14 USES)	270	RC						Both			630	283.5	283.5	567	409.5							Fee Schedule		466.2							Fee Schedule																													567							Fee Schedule																																															
INTUIT LG CLIP APPLIER 470230 (100 USES)	270	RC						Both			45	20.25	20.25	40.5	29.25							Fee Schedule		33.3							Fee Schedule																													40.5							Fee Schedule																																															
INTUIT LG NEEDLE DRIVER 471006 (15 USES)	270	RC						Both			536	241.2	241.2	482.4	348.4							Fee Schedule		396.64							Fee Schedule																													482.4							Fee Schedule																																															
INTUIT LONG BIP GRASPER 471400 (14 USES)	270	RC						Both			914	411.3	411.3	822.6	594.1							Fee Schedule		676.36							Fee Schedule																													822.6							Fee Schedule																																															
INTUIT MED-LG CLIP APP 420327 (100 USES)	270	RC						Both			45	20.25	20.25	40.5	29.25							Fee Schedule		33.3							Fee Schedule																													40.5							Fee Schedule																																															
INTUIT MEGA NEED DRIVER 470194 (10 USES)	270	RC						Both			693	311.85	311.85	623.7	450.45							Fee Schedule		512.82							Fee Schedule																													623.7							Fee Schedule																																															
INTUIT MEGA NEEDLE DRIV 471309 (15 USES)	270	RC						Both			552	248.4	248.4	496.8	358.8							Fee Schedule		408.48							Fee Schedule																													496.8							Fee Schedule																																															
INTUIT MONO CURV SCISS 470179 (10 USES)	270	RC						Both			1008	453.6	453.6	907.2	655.2							Fee Schedule		745.92							Fee Schedule																													907.2							Fee Schedule																																															
INTUIT PERMA CAUT HOOK 470183 (10 USES)	270	RC						Both			378	170.1	170.1	340.2	245.7							Fee Schedule		279.72							Fee Schedule																													340.2							Fee Schedule																																															
INTUIT PRO GRASP FORCEP 471093 (18 USES)	270	RC						Both			473	212.85	212.85	425.7	307.45							Fee Schedule		350.02							Fee Schedule																													425.7							Fee Schedule																																															
INTUIT TIP UP FEN GRASP 470347 (10 USES)	270	RC						Both			693	311.85	311.85	623.7	450.45							Fee Schedule		512.82							Fee Schedule																													623.7							Fee Schedule																																															
INTUITIVE 12 - 8 MM REDUCER #470381	272	RC						Both			79	35.55	35.55	71.1	51.35							Fee Schedule		58.46							Fee Schedule																													71.1							Fee Schedule																																															
INTUITIVE 12MM OBTURATOR 470395	272	RC						Both			1857	835.65	835.65	1671.3	1207.05							Fee Schedule		1374.18							Fee Schedule																													1671.3							Fee Schedule																																															
INTUITIVE 5-8MM CANN SEAL 470361 *DISC*	272	RC						Both			57	25.65	25.65	51.3	37.05							Fee Schedule		42.18							Fee Schedule																													51.3							Fee Schedule																																															
INTUITIVE 8MM BLADELESS OBTURATOR 470359	272	RC						Both			95	42.75	42.75	85.5	61.75							Fee Schedule		70.3							Fee Schedule																													85.5							Fee Schedule																																															
INTUITIVE BLADELESS OBTURATOR LON 470360	272	RC						Both			95	42.75	42.75	85.5	61.75							Fee Schedule		70.3							Fee Schedule																													85.5							Fee Schedule																																															
INTUITIVE COLUMN DRAPE #470341	272	RC						Both			57	25.65	25.65	51.3	37.05							Fee Schedule		42.18							Fee Schedule																													51.3							Fee Schedule																																															
INTUITIVE ENDOWRIST SUCTION IRR. #480299	272	RC						Both			835	375.75	375.75	751.5	542.75							Fee Schedule		617.9							Fee Schedule																													751.5							Fee Schedule																																															
INTUITIVE INSTRUMENT ARM DRAPE #470015	272	RC						Both			164	73.8	73.8	147.6	106.6							Fee Schedule		121.36							Fee Schedule																													147.6							Fee Schedule																																															
INTUITIVE RELOAD 45 BLUE 3.5 48345B	272	RC						Both			630	283.5	283.5	567	409.5							Fee Schedule		466.2							Fee Schedule																													567							Fee Schedule																																															
INTUITIVE RELOAD 45 GREEN 4.3 #48345G	272	RC						Both			630	283.5	283.5	567	409.5							Fee Schedule		466.2							Fee Schedule																													567							Fee Schedule																																															
INTUITIVE RELOAD 45 WHITE 2.5 #48345W	272	RC						Both			630	283.5	283.5	567	409.5							Fee Schedule		466.2							Fee Schedule																													567							Fee Schedule																																															
INTUITIVE RELOAD 60 BLUE 3.5 #48360B	272	RC						Both			725	326.25	326.25	652.5	471.25							Fee Schedule		536.5							Fee Schedule																													652.5							Fee Schedule																																															
INTUITIVE RELOAD 60 GREEN 4.3 #48360G	272	RC						Both			725	326.25	326.25	652.5	471.25							Fee Schedule		536.5							Fee Schedule																													652.5							Fee Schedule																																															
INTUITIVE RELOAD 60 WHITE 2.5 #48360W	272	RC						Both			725	326.25	326.25	652.5	471.25							Fee Schedule		536.5							Fee Schedule																													652.5							Fee Schedule																																															
INTUITIVE STAPLER SUREFORM 45 #480445	272	RC						Both			1449	652.05	652.05	1304.1	941.85							Fee Schedule		1072.26							Fee Schedule																													1304.1							Fee Schedule																																															
INTUITIVE STAPLER SUREFORM 60 #480460	272	RC						Both			1670	751.5	751.5	1503	1085.5							Fee Schedule		1235.8							Fee Schedule																													1503							Fee Schedule																																															
INTUITIVE TIP COVER ACCESSORY #400180	272	RC						Both			63	28.35	28.35	56.7	40.95							Fee Schedule		46.62							Fee Schedule																													56.7							Fee Schedule																																															
INTUITIVE UNIVERSAL SEAL 470500	272	RC						Both			60	27	27	54	39							Fee Schedule		44.4							Fee Schedule																													54							Fee Schedule																																															
INTUITIVE VESSEL SEALER EXTEND #480422	272	RC						Both			1969	886.05	886.05	1772.1	1279.85							Fee Schedule		1457.06							Fee Schedule																													1772.1							Fee Schedule																																															
INVIRASE 200MG  CAPS	250	RC	A9270	CPT				Both			8.4	3.78	0.01	7.56	0.01							Fee Schedule		6.22							Fee Schedule																													7.56							Fee Schedule																																															
IOBAN 2 DRAPE 6650EZ (SENECA)	270	RC						Both			23.1	10.4	10.4	20.79	15.02							Fee Schedule		17.09							Fee Schedule																													20.79							Fee Schedule																																															
IOBAN 2 DRAPE 6651EZ	270	RC						Both			29	13.05	13.05	26.1	18.85							Fee Schedule		21.46							Fee Schedule																													26.1							Fee Schedule																																															
IODINE 16599 1 ML SERUM PLASMA DARK BLU	301	RC	83789	CPT				Both			144.9	65.21	17.36	130.41	17.36							Fee Schedule		24.11							Fee Schedule		24.83							Fee Schedule		24.11							Fee Schedule											130.41							Fee Schedule																				24.11							Fee Schedule																				
IODINE 24 HR URINE 16602	301	RC	82542	CPT				Both			210	94.5	17.34	189	17.34							Fee Schedule		24.09							Fee Schedule		24.81							Fee Schedule		24.09							Fee Schedule		24.11							Fee Schedule		189							Fee Schedule		27.73							Fee Schedule		22.42							Fee Schedule		24.09							Fee Schedule		27.73							Fee Schedule		22.42							Fee Schedule		
IODINE STRONG SOLUTION (LUGOL'S)	250	RC	A9270	CPT				Both			67.63	30.43	0.01	60.87	0.01							Fee Schedule		50.05							Fee Schedule																				24.09							Fee Schedule		60.87							Fee Schedule		27.7							Fee Schedule		22.4							Fee Schedule											27.7							Fee Schedule		22.4							Fee Schedule		
IODOFORM 1 1/4	272	RC	A6407	CPT				Both			11	4.95	1.64	9.9	1.69							Fee Schedule		8.14							Fee Schedule		2.74							Fee Schedule		1.64							Fee Schedule											9.9							Fee Schedule																																															
IODOFORM 1 X5YD #7833	272	RC	A6407	CPT				Both			7	3.15	1.64	6.3	1.69							Fee Schedule		5.18							Fee Schedule		2.74							Fee Schedule		1.64							Fee Schedule		2.66							Fee Schedule		6.3							Fee Schedule		3.06							Fee Schedule		2.47							Fee Schedule											3.06							Fee Schedule		2.47							Fee Schedule		
IODOFORM 1/2 X5YD #NON256125	272	RC	A6407	CPT				Both			5	2.25	1.64	4.5	1.69							Fee Schedule		3.7							Fee Schedule		2.74							Fee Schedule		1.64							Fee Schedule		2.66							Fee Schedule		4.5							Fee Schedule		3.06							Fee Schedule		2.47							Fee Schedule											3.06							Fee Schedule		2.47							Fee Schedule		
IODOFORM 1/4 X5YD #NON256145	272	RC	A6266	CPT				Both			5	2.25	1.73	4.5	1.73							Fee Schedule		3.7							Fee Schedule		2.8							Fee Schedule		2.16							Fee Schedule		2.66							Fee Schedule		4.5							Fee Schedule		3.06							Fee Schedule		2.47							Fee Schedule											3.06							Fee Schedule		2.47							Fee Schedule		
IODOFORM PLAIN 1/2 X5YD #NON255125	272	RC	A6407	CPT				Both			5	2.25	1.64	4.5	1.69							Fee Schedule		3.7							Fee Schedule		2.74							Fee Schedule		1.64							Fee Schedule		2.72							Fee Schedule		4.5							Fee Schedule		3.13							Fee Schedule		2.53							Fee Schedule											3.13							Fee Schedule		2.53							Fee Schedule		
IODOFORM PLAIN 1/4  #NON255145	272	RC	A6407	CPT				Both			5	2.25	1.64	4.5	1.69							Fee Schedule		3.7							Fee Schedule		2.74							Fee Schedule		1.64							Fee Schedule		2.66							Fee Schedule		4.5							Fee Schedule		3.06							Fee Schedule		2.47							Fee Schedule											3.06							Fee Schedule		2.47							Fee Schedule		
IODOFORM1/4	272	RC						Both			13.65	6.14	2.47	12.29	8.87							Fee Schedule		10.1							Fee Schedule																				2.66							Fee Schedule		12.29							Fee Schedule		3.06							Fee Schedule		2.47							Fee Schedule											3.06							Fee Schedule		2.47							Fee Schedule		
IODOSORB GEL 10GM TUBE #6602124014	272	RC	A6248	CPT				Both			44	19.8	14.63	39.6	14.63							Fee Schedule		32.56							Fee Schedule		23.84							Fee Schedule		18.29							Fee Schedule											39.6							Fee Schedule																																															
IODOSORB GEL 40 GM TUBE	250	RC	A9270	CPT				Both			431.55	194.2	0.01	388.4	0.01							Fee Schedule		319.35							Fee Schedule																				23.15							Fee Schedule		388.4							Fee Schedule		26.62							Fee Schedule		21.53							Fee Schedule											26.62							Fee Schedule		21.53							Fee Schedule		
IODOSORB GEL 40GM TUBE #6602125040	272	RC	A6261	CPT				Both			140	63	2.08	126	2.08							Fee Schedule		103.6							Fee Schedule																													126							Fee Schedule																																															
IODOSORB PAD 1.5X 2 3/8  #6602133005	272	RC						Both			14.7	6.62	6.62	13.23	9.56							Fee Schedule		10.88							Fee Schedule																													13.23							Fee Schedule																																															
IP FUROSEMIDE 20MG/2ML (LASIX) INJECTION	636	RC	J1940	CPT				Both			12.6	5.67	5.67	11.34		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	9.32							Fee Schedule																													11.34							Fee Schedule																																															
IP IRRIGATION TRAY #DYND20100	272	RC	A4320	CPT				Both			10	4.5	4.11	9	4.11							Fee Schedule		7.4							Fee Schedule		6.72							Fee Schedule		5.14							Fee Schedule											9							Fee Schedule																																															
IPECAC SYRUP 30ML BOTTLE	250	RC	A9270	CPT				Both			5.25	2.36	0.01	7.5	0.01							Fee Schedule		3.89							Fee Schedule																				6.52							Fee Schedule		4.73							Fee Schedule		7.5							Fee Schedule		6.06							Fee Schedule											7.5							Fee Schedule		6.06							Fee Schedule		
IPOL-5ML VACCINE VIAL	636	RC	90713	CPT				Both			57.75	25.99	25.99	56.83		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	42.74							Fee Schedule											56.83							Fee Schedule											51.98							Fee Schedule																																															
IPPB CIRCUITS 1560 (SENECA)	272	RC						Both			8.4	3.78	3.78	7.56	5.46							Fee Schedule		6.22							Fee Schedule																													7.56							Fee Schedule																																															
IPPB FILTER BIPAP DYNJAABV1	270	RC						Both			2	0.9	0.9	1.8	1.3							Fee Schedule		1.48							Fee Schedule																													1.8							Fee Schedule																																															
IPPB INIT PROVENT/ATROVENT	412	RC	94640	CPT				Both			283.5	127.58	12.53	286	175							Per Diem		209.79							Fee Schedule											12.53							Fee Schedule											255.15							Fee Schedule																				286							Case Rate																				
IPPB INIT W/0.63 XOPENEX	412	RC	94640	CPT				Both			283.5	127.58	12.53	286	175							Per Diem		209.79							Fee Schedule											12.53							Fee Schedule											255.15							Fee Schedule																				286							Case Rate																				
IPPB INIT W/LIDOCAINE	412	RC	94640	CPT				Both			283.5	127.58	12.53	286	175							Per Diem		209.79							Fee Schedule											12.53							Fee Schedule											255.15							Fee Schedule																				286							Case Rate																				
IPPB MASK #329-03851410SFPE ( TRIANIM )	271	RC						Both			6.3	2.84	2.84	5.67	4.1							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
IPPB TREATMENT	412	RC	94640	CPT				Both			283.5	127.58	12.53	286	175							Per Diem		209.79							Fee Schedule											12.53							Fee Schedule											255.15							Fee Schedule																				286							Case Rate																				
IPRATROPIUM  NASAL SPRAY 0.03%-30ML	250	RC	A9270	CPT				Both			143.85	64.73	0.01	129.47	0.01							Fee Schedule		106.45							Fee Schedule																													129.47							Fee Schedule																																															
IPRATROPIUM 0.02% UD(RT)	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
IROM ELBW SP LT S/L	274	RC	L3740	CPT				Both			253.05	113.87	113.87	1239.46		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	187.26							Fee Schedule		1239.46							Fee Schedule		950.34							Fee Schedule											227.75							Fee Schedule																																															
IROM ELBW SP RT S/L	274	RC	L3740	CPT				Both			253.05	113.87	113.87	1383.86		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	187.26							Fee Schedule		1239.46							Fee Schedule		950.34							Fee Schedule		1203.36							Fee Schedule		227.75							Fee Schedule		1383.86							Fee Schedule		1119.12							Fee Schedule											1383.86							Fee Schedule		1119.12							Fee Schedule		
IRON	301	RC	83540	CPT				Both			100.8	45.36	5.75	1383.86	5.75							Fee Schedule		7.19							Fee Schedule		6.66							Fee Schedule		6.47							Fee Schedule		1203.36							Fee Schedule		90.72							Fee Schedule		1383.86							Fee Schedule		1119.12							Fee Schedule		6.47							Fee Schedule		1383.86							Fee Schedule		1119.12							Fee Schedule		
IRR SET 2 LEAD ARTHO	272	RC						Both			29.4	13.23	6.02	26.46	19.11							Fee Schedule		21.76							Fee Schedule																				6.47							Fee Schedule		26.46							Fee Schedule		7.44							Fee Schedule		6.02							Fee Schedule											7.44							Fee Schedule		6.02							Fee Schedule		
IRRIGATER EVAC	272	RC						Both			149.1	67.1	67.1	134.19	96.92							Fee Schedule		110.33							Fee Schedule																													134.19							Fee Schedule																																															
IRRIGATION CATH	272	RC						Both			52.5	23.63	23.63	47.25	34.13							Fee Schedule		38.85							Fee Schedule																													47.25							Fee Schedule																																															
IRRIGATION SYRINGE	272	RC						Both			3.15	1.42	1.42	2.84	2.05							Fee Schedule		2.33							Fee Schedule																													2.84							Fee Schedule																																															
IRRIGATION SYRINGE W/ ENFIT #8884700116E	270	RC	A4320	CPT				Both			10	4.5	4.11	9	4.11							Fee Schedule		7.4							Fee Schedule		6.72							Fee Schedule		5.14							Fee Schedule											9							Fee Schedule																																															
IRRIGATION TRAY	272	RC						Both			7.35	3.31	3.31	7.5	4.78							Fee Schedule		5.44							Fee Schedule																				6.52							Fee Schedule		6.62							Fee Schedule		7.5							Fee Schedule		6.06							Fee Schedule											7.5							Fee Schedule		6.06							Fee Schedule		
IRRIGATION TRAY #DYND20100 (DON'T ORDER)	272	RC	A4320	CPT				Both			10	4.5	4.11	9	4.11							Fee Schedule		7.4							Fee Schedule		6.72							Fee Schedule		5.14							Fee Schedule											9							Fee Schedule																																															
IRRIGATION TRAY W/ 60ML PISTON DYND20300	272	RC	A4320	CPT				Both			3	1.35	1.35	7.5	4.11							Fee Schedule		2.22							Fee Schedule		6.72							Fee Schedule		5.14							Fee Schedule		6.52							Fee Schedule		2.7							Fee Schedule		7.5							Fee Schedule		6.06							Fee Schedule											7.5							Fee Schedule		6.06							Fee Schedule		
IRRIGATION TUBING 250-070-500 STRYKER EN	272	RC						Both			178	80.1	6.06	160.2	115.7							Fee Schedule		131.72							Fee Schedule																				6.52							Fee Schedule		160.2							Fee Schedule		7.5							Fee Schedule		6.06							Fee Schedule											7.5							Fee Schedule		6.06							Fee Schedule		
IRRIGATION TUBING MECTRA LABS	272	RC						Both			68.25	30.71	30.71	61.43	44.36							Fee Schedule		50.51							Fee Schedule																													61.43							Fee Schedule																																															
ISENTRESS (RALTEGRAVIR)  400MG TABLET	250	RC	A9270	CPT				Both			94.5	42.53	0.01	85.05	0.01							Fee Schedule		69.93							Fee Schedule																													85.05							Fee Schedule																																															
ISLAND DRESSING 4X14 7544	272	RC	A6220	CPT				Both			4	1.8	1.8	3.8	2.33							Fee Schedule		2.96							Fee Schedule		3.8							Fee Schedule		2.91							Fee Schedule											3.6							Fee Schedule																																															
ISLAND DRESSING MSC3248Z PURCHASING	272	RC	A6220	CPT				Both			2	0.9	0.9	4.24	2.33							Fee Schedule		1.48							Fee Schedule		3.8							Fee Schedule		2.91							Fee Schedule		3.69							Fee Schedule		1.8							Fee Schedule		4.24							Fee Schedule		3.43							Fee Schedule											4.24							Fee Schedule		3.43							Fee Schedule		
ISLET CELL AB 36741 2ML SERUM	302	RC	86341	CPT				Both			90.3	40.64	3.43	81.27	17.59							Fee Schedule		23.57							Fee Schedule		24.28							Fee Schedule		23.57							Fee Schedule		3.69							Fee Schedule		81.27							Fee Schedule		4.24							Fee Schedule		3.43							Fee Schedule		23.57							Fee Schedule		4.24							Fee Schedule		3.43							Fee Schedule		
ISOLATION DRAPE ISO6619 NEW#6960	270	RC						Both			124	55.8	21.92	111.6	80.6							Fee Schedule		91.76							Fee Schedule																				23.57							Fee Schedule		111.6							Fee Schedule		27.11							Fee Schedule		21.92							Fee Schedule											27.11							Fee Schedule		21.92							Fee Schedule		
ISONIAZID 100 MG TABLET UD	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
ISONIAZID 300 MG TABLET UD	250	RC	A9270	CPT				Both			5.25	2.36	0.01	4.73	0.01							Fee Schedule		3.89							Fee Schedule																													4.73							Fee Schedule																																															
ISOPT CARPINE 3% OPTH.SOL -15 ML	250	RC	A9270	CPT				Both			33.64	15.14	0.01	30.28	0.01							Fee Schedule		24.89							Fee Schedule																													30.28							Fee Schedule																																															
ISOPT CARPINE 3% OTHL SOLN-15ML	250	RC	A9270	CPT				Both			38.59	17.37	0.01	34.73	0.01							Fee Schedule		28.56							Fee Schedule																													34.73							Fee Schedule																																															
ISOPTIN INJECTABLE	250	RC						Both			3.78	1.7	1.7	3.4	2.46							Fee Schedule		2.8							Fee Schedule																													3.4							Fee Schedule																																															
ISOSORBIDE DINIT 40MG ER (ISOCHRON) TAB	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
ISOSORBIDE DINITRATE 10MG (ISORDIL) TAB	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
ISOSORBIDE DINITRATE 20MG (ISORDIL) TAB	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
ISOSORBIDE DINITRATE 30MG (ISORDIL) TAB	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
ISOSORBIDE DINITRATE 5MG (ISORDIL) TAB	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
ISOSORBIDE MONONITRATE 10MG TAB	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
ISOSORBIDE MONONITRATE 20MG TAB	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
ISOSORBIDE MONONITRATE ER 30MG TAB	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
ISOSORBIDE MONONITRATE ER 60MG TAB	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
ISOVUE 300/50 ML	636	RC	Q9962	CPT				Both			97.65	43.94	43.94	87.89		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	72.26							Fee Schedule																													87.89							Fee Schedule																																															
ISRADIPINE 2.5 MG CAPSULE UD	250	RC	A9270	CPT				Both			4.2	1.89	0.01	3.78	0.01							Fee Schedule		3.11							Fee Schedule																													3.78							Fee Schedule																																															
ISUPREL 0.2MG/ML (1:5000) AMP	250	RC						Both			65.68	29.56	29.56	59.11	42.69							Fee Schedule		48.6							Fee Schedule																													59.11							Fee Schedule																																															
ISUPREL 1:200 PER ML (RT)	636	RC	J7658	CPT				Both			5.25	2.36	2.36	4.73		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	3.89							Fee Schedule																													4.73							Fee Schedule																																															
ITRACONAZOLE 100MG (SPORANOX) CAPSULE	250	RC	A9270	CPT				Both			49.35	22.21	0.01	44.42	0.01							Fee Schedule		36.52							Fee Schedule																													44.42							Fee Schedule																																															
ITRACONAZOLE 94092 SERUM 2ML FZ	301	RC	82542	CPT				Both			207.9	93.56	17.34	187.11	17.34							Fee Schedule		24.09							Fee Schedule		24.81							Fee Schedule		24.09							Fee Schedule											187.11							Fee Schedule																				24.09							Fee Schedule																				
IUD LILETTA  ( ANDA MEDS INC. )	636	RC	J7297	CPT				Both			1586.55	713.95	22.4	1427.9		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1174.05							Fee Schedule											1203.33							Fee Schedule		24.09							Fee Schedule		1427.9							Fee Schedule		27.7							Fee Schedule		22.4							Fee Schedule											27.7							Fee Schedule		22.4							Fee Schedule		
IUD MIRENA #50419-0421-01( MIRENA DIRECT	636	RC	J7298	CPT				Both			2703.75	1216.69	1216.69	2433.38		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	2000.78							Fee Schedule											1565.1							Fee Schedule											2433.38							Fee Schedule																																															
IUD PARA GARD T380-01(PARAGARD DIRECT CO	636	RC	J7300	CPT				Both			2327.85	1047.53	1047.53	2095.07		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1722.61							Fee Schedule											1459.6							Fee Schedule											2095.07							Fee Schedule																																															
IUD SKYLA (MIRENA DIRECT)	250	RC	J7301	CPT				Both			2251.2	1013.04	793.96	2026.08	793.96							Fee Schedule		1665.89							Fee Schedule											1303.21							Fee Schedule											2026.08							Fee Schedule																																															
IUPC KITS KOALA IPC-5000E	272	RC						Both			436	196.2	196.2	392.4	283.4							Fee Schedule		322.64							Fee Schedule																													392.4							Fee Schedule																																															
IV CATHETER	272	RC						Both			5.25	2.36	2.36	4.73	3.41							Fee Schedule		3.89							Fee Schedule																													4.73							Fee Schedule																																															
IV FILTER 0.22 MICRON #2C8671	272	RC						Both			9	4.05	4.05	8.1	5.85							Fee Schedule		6.66							Fee Schedule																													8.1							Fee Schedule																																															
IV FILTER FATS #2H8603	272	RC						Both			14	6.3	6.3	12.6	9.1							Fee Schedule		10.36							Fee Schedule																													12.6							Fee Schedule																																															
IV HYDRATION 1ST HOUR	260	RC	96360	CPT				Both			306	137.7	42.29	275.4	42.29							Fee Schedule		226.44							Fee Schedule											43.83							Fee Schedule											275.4							Fee Schedule																																															
IV HYDRATION EACH ADD'L HOUR	260	RC	96361	CPT				Both			84	37.8	12.58	75.6	12.58							Fee Schedule		62.16							Fee Schedule											12.81							Fee Schedule											75.6							Fee Schedule																																															
IV LARGE VOLUME WITH DRUG INFUSION	260	RC	96368	CPT				Both			126	56.7	16.16	113.4	19.22							Fee Schedule		93.24							Fee Schedule											16.16							Fee Schedule											113.4							Fee Schedule																																															
IV PUSH -EACH ADDITIONAL	260	RC	96376	CPT				Both			115.5	51.98	10.7	103.95	11.06							Fee Schedule		85.47							Fee Schedule											10.7							Fee Schedule											103.95							Fee Schedule																																															
IV PUSH NEW DRUG EACH ADDITIONAL	260	RC	96375	CPT				Both			126	56.7	16.43	113.4	16.43							Fee Schedule		93.24							Fee Schedule											18.44							Fee Schedule											113.4							Fee Schedule																																															
IV PUSH SINGLE OR INITIAL DRUG SUBSTANCE	260	RC	96374	CPT				Both			150.15	67.57	42	135.14	42							Fee Schedule		111.11							Fee Schedule											42.46							Fee Schedule											135.14							Fee Schedule																																															
IV RL 1000CC	258	RC						Both			34.65	15.59	15.59	31.19	22.52							Fee Schedule		25.64							Fee Schedule																													31.19							Fee Schedule																																															
IV SET (NO PORTS) #1C8109	272	RC						Both			6	2.7	2.7	5.4	3.9							Fee Schedule		4.44							Fee Schedule																													5.4							Fee Schedule																																															
IV SET W/ DUO-VENT #ACT8419	270	RC						Both			7	3.15	3.15	6.3	4.55							Fee Schedule		5.18							Fee Schedule																													6.3							Fee Schedule																																															
IV SITE CARE/DRESSING CHANGE	270	RC						Both			54.6	24.57	24.57	49.14	35.49							Fee Schedule		40.4							Fee Schedule																													49.14							Fee Schedule																																															
I-VAC 2160	272	RC						Both			73.5	33.08	33.08	66.15	47.78							Fee Schedule		54.39							Fee Schedule																													66.15							Fee Schedule																																															
IVENT BREATHING CIRCUIT #M1171508 SENECA	271	RC						Both			43.05	19.37	19.37	38.75	27.98							Fee Schedule		31.86							Fee Schedule																													38.75							Fee Schedule																																															
IVERMECTIN 15MG CAPSULE (STROMECTOL)	250	RC	A9270	CPT				Both			78.75	35.44	0.01	70.88	0.01							Fee Schedule		58.28							Fee Schedule																													70.88							Fee Schedule																																															
IVERMECTIN 3MG TABLET (STROMECTOL)	250	RC	A9270	CPT				Both			15.75	7.09	0.01	14.18	0.01							Fee Schedule		11.66							Fee Schedule																													14.18							Fee Schedule																																															
IVP REGULAR	320	RC	74400	CPT				Both			329.7	148.37	47.67	318	69.75							Fee Schedule		86.24							Fee Schedule											47.67							Fee Schedule											296.73							Fee Schedule																				318							Per Diem																				
J 4.0 415	272	RC						Both			13.65	6.14	6.14	12.29	8.87							Fee Schedule		10.1							Fee Schedule																													12.29							Fee Schedule																																															
JACKSON PRATT BULB #SU130-1305	272	RC						Both			34	15.3	15.3	30.6	22.1							Fee Schedule		25.16							Fee Schedule																													30.6							Fee Schedule																																															
JACKSON PRATT DRAIN	272	RC						Both			91.35	41.11	41.11	82.22	59.38							Fee Schedule		67.6							Fee Schedule																													82.22							Fee Schedule																																															
JADA SYSTEM VACUUM HEMORRHAGE CONTROL	270	RC						Both			4185	1883.25	1883.25	3766.5	2720.25							Fee Schedule		3096.9							Fee Schedule																													3766.5							Fee Schedule																																															
JAGTOME PRO RX 44 #M00584450	272	RC						Both			945	425.25	425.25	850.5	614.25							Fee Schedule		699.3							Fee Schedule																													850.5							Fee Schedule																																															
JAGUAR ARTHROSCOPY BLADE (STRYKER ENDOSC	272	RC						Both			197.4	88.83	88.83	177.66	128.31							Fee Schedule		146.08							Fee Schedule																													177.66							Fee Schedule																																															
JAGUAR ARTHROSCOPY BLADE (STRYKER ENDOSC	272	RC						Both			354.9	159.71	159.71	319.41	230.69							Fee Schedule		262.63							Fee Schedule																													319.41							Fee Schedule																																															
JAGWIRE ANGLED TIP #M00556591	272	RC	C1769	CPT				Both			707	318.15	154.26	636.3	154.26							Fee Schedule		523.18							Fee Schedule																													636.3							Fee Schedule																																															
JAK2 MUTATION 92473 5ML EDTA WB	310	RC	81270	CPT				Both			921.9	414.86	81.48	829.71	81.48							Fee Schedule		101.85							Fee Schedule		94.41							Fee Schedule		91.66							Fee Schedule											829.71							Fee Schedule																																															
JAK2 TARGETED SEQUENCE ANALYSIS	301	RC	81279	CPT				Both			2275	1023.75	85.24	2047.5	1478.75							Fee Schedule		185.2							Fee Schedule		190.76							Fee Schedule		185.2							Fee Schedule		91.66							Fee Schedule		2047.5							Fee Schedule		105.41							Fee Schedule		85.24							Fee Schedule		185.2							Fee Schedule		105.41							Fee Schedule		85.24							Fee Schedule		
JAMSHIDE NEEDLE DIN1515	272	RC						Both			32.55	14.65	14.65	212.98	21.16							Fee Schedule		24.09							Fee Schedule																				185.2							Fee Schedule		29.3							Fee Schedule		212.98							Fee Schedule		172.24							Fee Schedule											212.98							Fee Schedule		172.24							Fee Schedule		
JANSSEN COVID VACCINE ADMIN- BOOSTER	771	RC	0034A	CPT				Both			89.25	40.16	40.16	80.33	58.01							Fee Schedule		66.05							Fee Schedule																													80.33							Fee Schedule																																															
JANSSEN COVID-19 VACCINE ADMINSTRATION	771	RC	0031A	CPT				Both			89.25	40.16	40.16	80.33	58.01							Fee Schedule		66.05							Fee Schedule																													80.33							Fee Schedule																																															
JANUVIA (SITAGLIPTIN) 50 MG	250	RC	A9270	CPT				Both			48.3	21.74	0.01	43.47	0.01							Fee Schedule		35.74							Fee Schedule																													43.47							Fee Schedule																																															
JC VIRUS DNA QL PCR 17220	300	RC	87798	CPT				Both			189	85.05	31.2	170.1	31.2							Fee Schedule		38.99							Fee Schedule		36.14							Fee Schedule		35.09							Fee Schedule											170.1							Fee Schedule																				35.09							Fee Schedule																				
JEJUNAL FEEDING SET 10FR.	272	RC						Both			220.5	99.23	32.63	198.45	143.33							Fee Schedule		163.17							Fee Schedule																				35.09							Fee Schedule		198.45							Fee Schedule		40.35							Fee Schedule		32.63							Fee Schedule											40.35							Fee Schedule		32.63							Fee Schedule		
JEJUNAL FEEDING TUBE 0301-14	272	RC						Both			624	280.8	280.8	561.6	405.6							Fee Schedule		461.76							Fee Schedule																													561.6							Fee Schedule																																															
JEJUNAL FEEDING TUBE 18FR. 0200-18	272	RC						Both			425.25	191.36	191.36	382.73	276.41							Fee Schedule		314.69							Fee Schedule																													382.73							Fee Schedule																																															
JEJUNAL FEEDING TUBE 22 FR. 28CC BALLOON	272	RC						Both			414.75	186.64	186.64	373.28	269.59							Fee Schedule		306.92							Fee Schedule																													373.28							Fee Schedule																																															
JEJUNAL FEEDING TUBE 22FR.  # 0250-22	272	RC						Both			730.8	328.86	328.86	657.72	475.02							Fee Schedule		540.79							Fee Schedule																													657.72							Fee Schedule																																															
JEJUNOSTOMY FEED KIT 7 FR. #071287	272	RC						Both			269.85	121.43	121.43	242.87	175.4							Fee Schedule		199.69							Fee Schedule																													242.87							Fee Schedule																																															
JEVITY 1.2 CAL 237ML	250	RC	B4150	CPT				Both			6.3	2.84	0.21	5.67	0.21							Fee Schedule		4.66							Fee Schedule											0.84							Fee Schedule											5.67							Fee Schedule																																															
JEVITY 1.2 CAL RTH 1000ML	250	RC	B4150	CPT				Both			34.65	15.59	0.21	31.19	0.21							Fee Schedule		25.64							Fee Schedule											0.84							Fee Schedule											31.19							Fee Schedule																																															
JEVITY 1.5 CAL 237ML	250	RC	B4152	CPT				Both			6	2.7	0.17	5.4	0.17							Fee Schedule		4.44							Fee Schedule											0.69							Fee Schedule											5.4							Fee Schedule																																															
JEVITY 1.5 CAL RTH 1000ML	250	RC	B4152	CPT				Both			40.95	18.43	0.17	36.86	0.17							Fee Schedule		30.3							Fee Schedule											0.69							Fee Schedule											36.86							Fee Schedule																																															
JEVITY 240ML CAN	250	RC	B4150	CPT				Both			6.3	2.84	0.21	5.67	0.21							Fee Schedule		4.66							Fee Schedule											0.84							Fee Schedule											5.67							Fee Schedule																																															
JEVITY READY TO HANG 1000 ML	250	RC	B4150	CPT				Both			34.65	15.59	0.21	31.19	0.21							Fee Schedule		25.64							Fee Schedule											0.84							Fee Schedule											31.19							Fee Schedule																																															
JO 1 ANTIBODY  5810 SERUM	302	RC	86235	CPT				Both			193.2	86.94	15.94	173.88	15.94							Fee Schedule		19.93							Fee Schedule		18.47							Fee Schedule		17.93							Fee Schedule											173.88							Fee Schedule																				17.93							Fee Schedule																				
JO POLYOMA VIRUS DNA 19503 SERUM 1ML	302	RC	87799	CPT				Both			467.25	210.26	16.67	420.53	38.07							Fee Schedule		47.6							Fee Schedule		44.13							Fee Schedule		42.84							Fee Schedule		17.93							Fee Schedule		420.53							Fee Schedule		20.62							Fee Schedule		16.67							Fee Schedule		42.84							Fee Schedule		20.62							Fee Schedule		16.67							Fee Schedule		
JOBST COMPRESSION SLEEVE (CUSTOM)	270	RC						Both			85.05	38.27	38.27	76.55	55.28							Fee Schedule		62.94							Fee Schedule																				42.84							Fee Schedule		76.55							Fee Schedule		49.27							Fee Schedule		39.84							Fee Schedule											49.27							Fee Schedule		39.84							Fee Schedule		
JOBST STOCKING	271	RC						Both			131.25	59.06	59.06	118.13	85.31							Fee Schedule		97.13							Fee Schedule																													118.13							Fee Schedule																																															
J-STENT	278	RC	C2625	CPT				Both			416.85	187.58	187.58	375.17		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	308.47							Fee Schedule																													375.17							Fee Schedule																																															
J-TUBE OVER THE WIRE 8FR.	272	RC						Both			213.15	95.92	95.92	191.84	138.55							Fee Schedule		157.73							Fee Schedule																													191.84							Fee Schedule																																															
JUBBONTI SUBQ SOLN 60MG/1ML	636	RC	Q5136	CPT				Both			5774.88	2598.7	27.4	5197.39		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	27.4							Fee Schedule		29.08							Fee Schedule																				5197.39							Fee Schedule																																															
JURGAN BALLS 3/32	272	RC						Both			15.75	7.09	7.09	32.46	10.24							Fee Schedule		11.66							Fee Schedule																				28.23							Fee Schedule		14.18							Fee Schedule		32.46							Fee Schedule		26.25							Fee Schedule											32.46							Fee Schedule		26.25							Fee Schedule		
JURGAN BALLS 5/64	272	RC						Both			15.75	7.09	7.09	14.18	10.24							Fee Schedule		11.66							Fee Schedule																													14.18							Fee Schedule																																															
JURGAN BALLS W564-BL (JURGAN DEVELOPMENT	272	RC						Both			17.85	8.03	8.03	16.07	11.6							Fee Schedule		13.21							Fee Schedule																													16.07							Fee Schedule																																															
JURGEN BALLS .045  (JURGEN DEVELOPMENT)	272	RC						Both			17.85	8.03	8.03	16.07	11.6							Fee Schedule		13.21							Fee Schedule																													16.07							Fee Schedule																																															
JURGEN BALLS .062  (JURGEN DEVELOPMENT)	272	RC						Both			17.85	8.03	8.03	16.07	11.6							Fee Schedule		13.21							Fee Schedule																													16.07							Fee Schedule																																															
K MANI PUJECTOR	272	RC						Both			66.15	29.77	29.77	59.54	43							Fee Schedule		48.95							Fee Schedule																													59.54							Fee Schedule																																															
K WIRE .7	278	RC						Both			14.7	6.62	6.62	13.23		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	10.88							Fee Schedule																													13.23							Fee Schedule																																															
K WIRE .9	278	RC						Both			14.7	6.62	6.62	13.23		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	10.88							Fee Schedule																													13.23							Fee Schedule																																															
K WIRE 1.1	278	RC						Both			14.7	6.62	6.62	13.23		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	10.88							Fee Schedule																													13.23							Fee Schedule																																															
K WIRES 1.6	270	RC						Both			14.7	6.62	6.62	13.23	9.56							Fee Schedule		10.88							Fee Schedule																													13.23							Fee Schedule																																															
KALBITOR 10MG/ML INJECTION	636	RC	J1744	CPT				Both			16701.3	7515.59	7515.59	15031.17		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	12358.96							Fee Schedule																													15031.17							Fee Schedule																																															
KALOSTAT DRSG 3X8 EA	272	RC						Both			15.75	7.09	7.09	14.18	10.24							Fee Schedule		11.66							Fee Schedule																													14.18							Fee Schedule																																															
KALTOSTAT	272	RC						Both			17.85	8.03	8.03	16.07	11.6							Fee Schedule		13.21							Fee Schedule																													16.07							Fee Schedule																																															
KAM VAC # 5300-20-500  (DEPUY ORTHO)	270	RC						Both			300	135	135	270	195							Fee Schedule		222							Fee Schedule																													270							Fee Schedule																																															
KAM VAC SUCTION TUBE	270	RC						Both			135.45	60.95	60.95	121.91	88.04							Fee Schedule		100.23							Fee Schedule																													121.91							Fee Schedule																																															
KANAMYCIN 1 GM/3ML INJECITON	636	RC	J1840	CPT				Both			24.15	10.87	10.87	21.74		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	17.87							Fee Schedule																													21.74							Fee Schedule																																															
KANGAROO FEEDING BAG #773662	271	RC						Both			14	6.3	6.3	12.6	9.1							Fee Schedule		10.36							Fee Schedule																													12.6							Fee Schedule																																															
KANGAROO OMNI 1000ML PUMP SET B1 B10FD	270	RC	B4035	CPT				Both			7	3.15	3.05	14.47	3.05							Fee Schedule		5.18							Fee Schedule											14.47							Fee Schedule											6.3							Fee Schedule																																															
KANGAROO OMNI FEEDING BAG B10FF *NEW*	271	RC						Both			16	7.2	7.2	14.4	10.4							Fee Schedule		11.84							Fee Schedule																													14.4							Fee Schedule																																															
KANGAROO OMNI FEEDING SPIKED SET BSPFF	270	RC	B4035	CPT				Both			13	5.85	3.05	14.47	3.05							Fee Schedule		9.62							Fee Schedule											14.47							Fee Schedule											11.7							Fee Schedule																																															
KANGAROO PUMP SET SAFETY NEW # 775100	270	RC						Both			12	5.4	5.4	10.8	7.8							Fee Schedule		8.88							Fee Schedule																													10.8							Fee Schedule																																															
KANGAROO PUMP SET WITH SPIKE 774669 DISC	270	RC						Both			11.55	5.2	5.2	10.4	7.51							Fee Schedule		8.55							Fee Schedule																													10.4							Fee Schedule																																															
KAOCHLOR LIQ:10%	250	RC	A9270	CPT				Both			4.2	1.89	0.01	3.78	0.01							Fee Schedule		3.11							Fee Schedule																													3.78							Fee Schedule																																															
KAOPECTATE 262 MG/15ML  LIQUID-325ML	250	RC	A9270	CPT				Both			11.55	5.2	0.01	10.4	0.01							Fee Schedule		8.55							Fee Schedule																													10.4							Fee Schedule																																															
KAPPA LAMBDA 15122 3ML SERUM	300	RC	83883	CPT				Both			254.1	114.35	12.09	228.69	12.09							Fee Schedule		15.11							Fee Schedule		14.01							Fee Schedule		13.6							Fee Schedule											228.69							Fee Schedule																				13.6							Fee Schedule																				
KAPPA LAMBDA URINE 17300 2ML/24HR URINE	300	RC	83883	CPT				Both			220.5	99.23	12.09	198.45	12.09							Fee Schedule		15.11							Fee Schedule		14.01							Fee Schedule		13.6							Fee Schedule		13.6							Fee Schedule		198.45							Fee Schedule		15.64							Fee Schedule		12.65							Fee Schedule		13.6							Fee Schedule		15.64							Fee Schedule		12.65							Fee Schedule		
KARAYA PASTE	272	RC						Both			42	18.9	12.65	37.8	27.3							Fee Schedule		31.08							Fee Schedule																				13.6							Fee Schedule		37.8							Fee Schedule		15.64							Fee Schedule		12.65							Fee Schedule											15.64							Fee Schedule		12.65							Fee Schedule		
KARAYA POWDER 2.5OZ	272	RC						Both			23.1	10.4	10.4	20.79	15.02							Fee Schedule		17.09							Fee Schedule																													20.79							Fee Schedule																																															
KARAYA SKIN PROTECT	272	RC						Both			2.1	0.95	0.95	1.89	1.37							Fee Schedule		1.55							Fee Schedule																													1.89							Fee Schedule																																															
KATZ EXTRACTOR   BEX	270	RC						Both			104	46.8	46.8	93.6	67.6							Fee Schedule		76.96							Fee Schedule																													93.6							Fee Schedule																																															
KATZ EXTRACTOR OTO-RHINO # FB-5000	270	RC						Both			240	108	108	216	156							Fee Schedule		177.6							Fee Schedule																													216							Fee Schedule																																															
K-CENTRA	636	RC	J7168	CPT				Both			6105.75	2747.59	2.16	5495.18		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	2.98							Fee Schedule		2.16							Fee Schedule																				5495.18							Fee Schedule																																															
KCL 10 MEQ/50ML PREMIX	258	RC						Both			34.65	15.59	1.95	31.19	22.52							Fee Schedule		25.64							Fee Schedule																				2.09							Fee Schedule		31.19							Fee Schedule		2.41							Fee Schedule		1.95							Fee Schedule											2.41							Fee Schedule		1.95							Fee Schedule		
KCL 20 MEQ. 100 PREMIX (BAXTER HEALTHCAR	258	RC						Both			32	14.4	14.4	28.8	20.8							Fee Schedule		23.68							Fee Schedule																													28.8							Fee Schedule																																															
K-DUR:10 MEQ TABLETS	250	RC	A9270	CPT				Both			1.58	0.71	0.01	1.42	0.01							Fee Schedule		1.17							Fee Schedule																													1.42							Fee Schedule																																															
KEFLEX CAP 500 MG (CEPHALEXIN)	250	RC	A9270	CPT				Both			7.72	3.47	0.01	6.95	0.01							Fee Schedule		5.71							Fee Schedule																													6.95							Fee Schedule																																															
KEFLEX PULV 250 MG (CEPHALEXIN)	250	RC	A9270	CPT				Both			3.99	1.8	0.01	3.59	0.01							Fee Schedule		2.95							Fee Schedule																													3.59							Fee Schedule																																															
KEFUROX 1.5 GM ADV	636	RC	J0697	CPT				Both			76.62	34.48	2.11	68.96		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	56.7							Fee Schedule		2.11							Fee Schedule		7.83							Fee Schedule											68.96							Fee Schedule																																															
KEFUROX 1.5 GM VIAL	636	RC	J0697	CPT				Both			43.31	19.49	1.9	38.98		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	32.05							Fee Schedule		2.11							Fee Schedule		7.83							Fee Schedule		2.04							Fee Schedule		38.98							Fee Schedule		2.35							Fee Schedule		1.9							Fee Schedule											2.35							Fee Schedule		1.9							Fee Schedule		
KEFUROX 1.5 GM VIAL	636	RC	J0697	CPT				Both			48.11	21.65	1.9	43.3		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	35.6							Fee Schedule		2.11							Fee Schedule		7.83							Fee Schedule		2.04							Fee Schedule		43.3							Fee Schedule		2.35							Fee Schedule		1.9							Fee Schedule											2.35							Fee Schedule		1.9							Fee Schedule		
KEFUROX 1.5 GM.+ NS 100 ML	636	RC	J0697	CPT				Both			46.2	20.79	1.9	41.58		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	34.19							Fee Schedule		2.11							Fee Schedule		7.83							Fee Schedule		2.04							Fee Schedule		41.58							Fee Schedule		2.35							Fee Schedule		1.9							Fee Schedule											2.35							Fee Schedule		1.9							Fee Schedule		
KEFUROX 750 MG + NS 100ML	636	RC	J0697	CPT				Both			36.75	16.54	1.9	33.08		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	27.2							Fee Schedule		2.11							Fee Schedule		7.83							Fee Schedule		2.04							Fee Schedule		33.08							Fee Schedule		2.35							Fee Schedule		1.9							Fee Schedule											2.35							Fee Schedule		1.9							Fee Schedule		
KEFUROX 750 MG VIAL	636	RC	J0697	CPT				Both			43.48	19.57	1.9	39.13		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	32.18							Fee Schedule		2.11							Fee Schedule		7.83							Fee Schedule		2.04							Fee Schedule		39.13							Fee Schedule		2.35							Fee Schedule		1.9							Fee Schedule											2.35							Fee Schedule		1.9							Fee Schedule		
KEFZOL 1GM	250	RC						Both			40.95	18.43	1.9	36.86	26.62							Fee Schedule		30.3							Fee Schedule																				2.04							Fee Schedule		36.86							Fee Schedule		2.35							Fee Schedule		1.9							Fee Schedule											2.35							Fee Schedule		1.9							Fee Schedule		
KEFZOL 1GM + NS 100 ML	636	RC	J0690	CPT				Both			39.38	17.72	0.82	35.44		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	29.14							Fee Schedule		0.82							Fee Schedule		3.62							Fee Schedule											35.44							Fee Schedule																																															
KEFZOL 500 MG VIAL	636	RC	J0690	CPT				Both			10.25	4.61	0.74	9.23		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	7.59							Fee Schedule		0.82							Fee Schedule		3.62							Fee Schedule		0.8							Fee Schedule		9.23							Fee Schedule		0.92							Fee Schedule		0.74							Fee Schedule											0.92							Fee Schedule		0.74							Fee Schedule		
KEFZOL PER GM ADV	636	RC	J0690	CPT				Both			43.29	19.48	0.74	38.96		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	32.03							Fee Schedule		0.82							Fee Schedule		3.62							Fee Schedule		0.8							Fee Schedule		38.96							Fee Schedule		0.92							Fee Schedule		0.74							Fee Schedule											0.92							Fee Schedule		0.74							Fee Schedule		
KEFZOL:1 GM VIAL 10 ML	636	RC	J0690	CPT				Both			13.27	5.97	0.74	11.94		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	9.82							Fee Schedule		0.82							Fee Schedule		3.62							Fee Schedule		0.8							Fee Schedule		11.94							Fee Schedule		0.92							Fee Schedule		0.74							Fee Schedule											0.92							Fee Schedule		0.74							Fee Schedule		
KENALOG .1% OINT  1LB JAR	250	RC	A9270	CPT				Both			67.2	30.24	0.01	60.48	0.01							Fee Schedule		49.73							Fee Schedule																				0.8							Fee Schedule		60.48							Fee Schedule		0.92							Fee Schedule		0.74							Fee Schedule											0.92							Fee Schedule		0.74							Fee Schedule		
KENDALL VASLINE GAUZE 421600	272	RC						Both			40.95	18.43	18.43	36.86	26.62							Fee Schedule		30.3							Fee Schedule																													36.86							Fee Schedule																																															
KENDALL VENTEX PRIMA	271	RC						Both			18.9	8.51	8.51	17.01	12.29							Fee Schedule		13.99							Fee Schedule																													17.01							Fee Schedule																																															
KENDALL VENTEX SECON	271	RC						Both			4.73	2.13	2.13	4.26	3.07							Fee Schedule		3.5							Fee Schedule																													4.26							Fee Schedule																																															
KERLIX 2 INCH STERILE	272	RC						Both			4.2	1.89	1.89	3.78	2.73							Fee Schedule		3.11							Fee Schedule																													3.78							Fee Schedule																																															
KERLIX 3  STERILE #NON25861	272	RC						Both			2	0.9	0.9	1.8	1.3							Fee Schedule		1.48							Fee Schedule																													1.8							Fee Schedule																																															
KERLIX 4  STERILE XRAY DETECTABLE #5360	272	RC						Both			5	2.25	2.25	4.5	3.25							Fee Schedule		3.7							Fee Schedule																													4.5							Fee Schedule																																															
KERLIX 4 1/2  #NON25865XR	272	RC						Both			4	1.8	1.8	3.6	2.6							Fee Schedule		2.96							Fee Schedule																													3.6							Fee Schedule																																															
KERLIX 4.5  STERILE #NON25865	272	RC						Both			2	0.9	0.9	1.8	1.3							Fee Schedule		1.48							Fee Schedule																													1.8							Fee Schedule																																															
KERLIX DRESS M SPNG	272	RC						Both			3.15	1.42	1.42	2.84	2.05							Fee Schedule		2.33							Fee Schedule																													2.84							Fee Schedule																																															
KERLIX SOFBAN	272	RC						Both			9.45	4.25	4.25	8.51	6.14							Fee Schedule		6.99							Fee Schedule																													8.51							Fee Schedule																																															
KETAMINE 50 MG/ML- 10ML INJECTION	250	RC	96365	CPT				Both			17.85	8.03	8.03	65.69	65.69							Fee Schedule		13.21							Fee Schedule											53.47							Fee Schedule											16.07							Fee Schedule																																															
KETAMINE 50 MG/ML SYRINGE- 1ML	250	RC						Both			13.65	6.14	6.14	12.29	8.87							Fee Schedule		10.1							Fee Schedule																													12.29							Fee Schedule																																															
KETAMINE STANDARD DRIP	250	RC	96365	CPT				Both			120.75	54.34	53.47	108.68	65.69							Fee Schedule		89.36							Fee Schedule											53.47							Fee Schedule											108.68							Fee Schedule																																															
KETEK 400 MG TABLET UD	250	RC	A9270	CPT				Both			21	9.45	0.01	18.9	0.01							Fee Schedule		15.54							Fee Schedule																													18.9							Fee Schedule																																															
KETOCONAZOLE 2% CREAM- 15GM	250	RC	A9270	CPT				Both			53.01	23.85	0.01	47.71	0.01							Fee Schedule		39.23							Fee Schedule																													47.71							Fee Schedule																																															
KETOCONAZOLE 200MG (NIZORAL) TABLET	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
KETONE 205 WHOLE BLOOD 1ML GRAY TOP TUBE	301	RC	82010	CPT				Both			26.25	11.81	7.26	23.63	7.26							Fee Schedule		9.08							Fee Schedule		8.42							Fee Schedule		8.17							Fee Schedule											23.63							Fee Schedule																				8.17							Fee Schedule																				
KETOROLAC 10MG (TORADOL) TABLET	250	RC	A9270	CPT				Both			6.3	2.84	0.01	9.4	0.01							Fee Schedule		4.66							Fee Schedule																				8.17							Fee Schedule		5.67							Fee Schedule		9.4							Fee Schedule		7.6							Fee Schedule											9.4							Fee Schedule		7.6							Fee Schedule		
KETOROLAC 30 MG/ML (TORADOL) INJECTION	636	RC	J1885	CPT				Both			18.9	8.51	0.34	17.01		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	0.34							Fee Schedule		0.34							Fee Schedule																				17.01							Fee Schedule																																															
KETOROLAC 60 MG/2 ML (TORADOL) INJECTION	636	RC	J1885	CPT				Both			24.15	10.87	0.31	21.74		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	0.34							Fee Schedule		0.34							Fee Schedule											0.33							Fee Schedule		21.74							Fee Schedule		0.38							Fee Schedule		0.31							Fee Schedule											0.38							Fee Schedule		0.31							Fee Schedule		
KETOSTEROIDS17 15201 24HR URINE	301	RC	83586	CPT				Both			86.1	38.75	0.31	77.49	11.38							Fee Schedule		14.22							Fee Schedule		13.18							Fee Schedule		12.8							Fee Schedule		0.33							Fee Schedule		77.49							Fee Schedule		0.38							Fee Schedule		0.31							Fee Schedule		12.8							Fee Schedule		0.38							Fee Schedule		0.31							Fee Schedule		
KETOTIFEN OPTH SOLUTION (ZADITOR)	250	RC	A9270	CPT				Both			36.75	16.54	0.01	33.08	0.01							Fee Schedule		27.2							Fee Schedule																				12.8							Fee Schedule		33.08							Fee Schedule		14.72							Fee Schedule		11.9							Fee Schedule											14.72							Fee Schedule		11.9							Fee Schedule		
OTHER DIGESTIVE SYSTEM DIAGNOSES WITHOUT CC/MCC					395	DRG		Inpatient			29753.84	13389.23	13389.23	13389.23							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback				6619.5	6619.5	6619.5	1 through 10									0		No services provided during 15 month lookback period	
APPENDIX PROCEDURES WITH MCC					397	DRG		Inpatient			92233.81	41505.21	41505.21	41505.21							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback				18381.04	18381.04	18381.04	1 through 10									0		No services provided during 15 month lookback period	
APPENDIX PROCEDURES WITH CC					398	DRG		Inpatient			33704.61	15167.07	15167.07	15167.07							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period	
APPENDIX PROCEDURES WITHOUT CC/MCC					399	DRG		Inpatient			30628.49	13782.82	13782.82	13782.82							0		No services performed during 15 month lookback period. 				3684	3684	3684	1 through 10									0		No services performed during 15 month lookback period							0		No services provided during 15 month lookback period				5176.9	5176.9	5176.9	1 through 10									0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period	
CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITH CC					415	DRG		Inpatient			28848.6	12981.87	12981.87	12981.87							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period	
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH MCC					417	DRG		Inpatient			59894.39	26952.47	26952.47	26952.47				7514.84	7514.84	7514.84	1 through 10									0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period							0		No services provided during 15 month lookback period				11515.39	11515.39	11515.39	1 through 10									0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period				8296.58	8296.58	8296.58	1 through 10									0		No services provided during 15 month lookback							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period	
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH CC					418	DRG		Inpatient			41940.84	18873.38	18873.38	18873.38				21923.3	21923.3	21923.3	1 through 10						4420.8	4420.8	4420.8	1 through 10									0		No services performed during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period				35394.39	35394.39	35394.39	1 through 10									0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback							0		No services provided during 15 month lookback period				6906.45	6906.45	6906.45	1 through 10			
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITHOUT CC/MCC					419	DRG		Inpatient			33953.81	15279.22	15279.22	15279.22							0		No services performed during 15 month lookback period. 				1684.17	1684.17	1684.17	1 through 10									0		No services performed during 15 month lookback period							0		No services provided during 15 month lookback period				7517.29	7517.29	7517.29	1 through 10									0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback				11782.53	11782.53	11782.53	1 through 10									0		No services provided during 15 month lookback period	
KINESIO ATHLETIC TAPE 2  #GKT15024	270	RC						Both			27	12.15	12.15	24.3	17.55							Fee Schedule		19.98							Fee Schedule																													24.3							Fee Schedule																																															
KINESIO ATHLETIC TAPE 3  #GKT15034	270	RC						Both			44	19.8	19.8	39.6	28.6							Fee Schedule		32.56							Fee Schedule																													39.6							Fee Schedule																																															
KINEVAC	250	RC	J2805	CPT				Both			162.75	73.24	73.24	146.48	110.93							Fee Schedule		120.44							Fee Schedule		113.78							Fee Schedule																				146.48							Fee Schedule																																															
KINEVAC 5 MCG INJECTION	250	RC						Both			84	37.8	37.8	127.03	54.6							Fee Schedule		62.16							Fee Schedule																				110.46							Fee Schedule		75.6							Fee Schedule		127.03							Fee Schedule		102.73							Fee Schedule											127.03							Fee Schedule		102.73							Fee Schedule		
KINRIX INJ.(DTAP-IPV) VACCINE 4-6 YR	636	RC	90696	CPT				Both			77.7	34.97	34.97	69.93		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	57.5							Fee Schedule																													69.93							Fee Schedule																																															
KIT D816 MUTATION ANAL 91772	310	RC	81273	CPT				Both			1377	619.65	89.91	1239.3	89.91							Fee Schedule		124.87							Fee Schedule		128.62							Fee Schedule		124.87							Fee Schedule											1239.3							Fee Schedule																																															
KIWI VACUUM DELIVERY SYSTEM VAC-6000M	272	RC						Both			93	41.85	41.85	143.6	60.45							Fee Schedule		68.82							Fee Schedule																				124.87							Fee Schedule		83.7							Fee Schedule		143.6							Fee Schedule		116.13							Fee Schedule											143.6							Fee Schedule		116.13							Fee Schedule		
KLEIHAUER-BETKE STAIN 34942 EDTA WB REF	305	RC	85460	CPT				Both			299.25	134.66	6.88	269.33	6.88							Fee Schedule		8.59							Fee Schedule		7.96							Fee Schedule		7.73							Fee Schedule											269.33							Fee Schedule																				7.73							Fee Schedule																				
KLEPENGER	272	RC						Both			310.8	139.86	7.19	279.72	202.02							Fee Schedule		229.99							Fee Schedule																				7.73							Fee Schedule		279.72							Fee Schedule		8.89							Fee Schedule		7.19							Fee Schedule											8.89							Fee Schedule		7.19							Fee Schedule		
KLING CONFORM 1  #NON254955	272	RC						Both			1	0.45	0.45	0.9	0.65							Fee Schedule		0.74							Fee Schedule																													0.9							Fee Schedule																																															
KLING CONFORM 2  #NON25496	272	RC	A6445	CPT				Both			1	0.45	0.28	0.9	0.29							Fee Schedule		0.74							Fee Schedule		0.46							Fee Schedule		0.28							Fee Schedule											0.9							Fee Schedule																																															
KLING CONFORM 3  #NON25497	272	RC						Both			1	0.45	0.42	0.9	0.65							Fee Schedule		0.74							Fee Schedule																				0.45							Fee Schedule		0.9							Fee Schedule		0.52							Fee Schedule		0.42							Fee Schedule											0.52							Fee Schedule		0.42							Fee Schedule		
KLING CONFORM 4  #NON25498	270	RC						Both			1	0.45	0.45	0.9	0.65							Fee Schedule		0.74							Fee Schedule																													0.9							Fee Schedule																																															
KLING CONFORM 6  #NON25499	272	RC						Both			1	0.45	0.45	0.9	0.65							Fee Schedule		0.74							Fee Schedule																													0.9							Fee Schedule																																															
K-LOR 20 MEQ/PACKET	250	RC	A9270	CPT				Both			5.25	2.36	0.01	4.73	0.01							Fee Schedule		3.89							Fee Schedule																													4.73							Fee Schedule																																															
KLOR-CON  8 MEQ (POTASS CHLORID) TABLET	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
KMI BIOBLACK SUBTALAR IMPLANT 04-0010	278	RC	C1776	CPT				Both			5376	2419.2	2419.2	4838.4		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	3978.24							Fee Schedule																													4838.4							Fee Schedule																																															
KMI BIOBLACK SUBTALAR IMPLANT 11 MM	278	RC	C1776	CPT				Both			5376	2419.2	2419.2	4838.4		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	3978.24							Fee Schedule																													4838.4							Fee Schedule																																															
KMI K-WIRE 05-0017	278	RC	C1776	CPT				Both			95.55	43	43	86		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	70.71							Fee Schedule																													86							Fee Schedule																																															
KNEE 1-2V LT	320	RC	73560	CPT				Both			315	141.75	15.04	318	18.51							Fee Schedule		21.62							Fee Schedule											15.04							Fee Schedule											283.5							Fee Schedule																				318							Per Diem																				
KNEE 1-2V RT	320	RC	73560	CPT				Both			315	141.75	15.04	318	18.51							Fee Schedule		21.62							Fee Schedule											15.04							Fee Schedule											283.5							Fee Schedule																				318							Per Diem																				
KNEE BRACE 19 INCH LARGE	272	RC						Both			73.5	33.08	33.08	66.15	47.78							Fee Schedule		54.39							Fee Schedule																													66.15							Fee Schedule																																															
KNEE BRACE 19 INCH MEDIUM	272	RC						Both			73.5	33.08	33.08	66.15	47.78							Fee Schedule		54.39							Fee Schedule																													66.15							Fee Schedule																																															
KNEE BRACE DONJOY	274	RC	L1832	CPT				Both			303.45	136.55	136.55	959.46		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	224.55							Fee Schedule		959.46							Fee Schedule		580.58							Fee Schedule											273.11							Fee Schedule																																															
KNEE BRACE HINGED 2XLG	274	RC	L1832	CPT				Both			157.5	70.88	70.88	1071.24		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	116.55							Fee Schedule		959.46							Fee Schedule		580.58							Fee Schedule		931.51							Fee Schedule		141.75							Fee Schedule		1071.24							Fee Schedule		866.3							Fee Schedule											1071.24							Fee Schedule		866.3							Fee Schedule		
KNEE BRACE HINGED LARGE	274	RC	L1832	CPT				Both			157.5	70.88	70.88	1071.24		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	116.55							Fee Schedule		959.46							Fee Schedule		580.58							Fee Schedule		931.51							Fee Schedule		141.75							Fee Schedule		1071.24							Fee Schedule		866.3							Fee Schedule											1071.24							Fee Schedule		866.3							Fee Schedule		
KNEE BRACE HINGED MED	274	RC	L1832	CPT				Both			157.5	70.88	70.88	1071.24		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	116.55							Fee Schedule		959.46							Fee Schedule		580.58							Fee Schedule		931.51							Fee Schedule		141.75							Fee Schedule		1071.24							Fee Schedule		866.3							Fee Schedule											1071.24							Fee Schedule		866.3							Fee Schedule		
KNEE BRACE HINGED X-LARGE	274	RC	L1832	CPT				Both			157.5	70.88	70.88	1071.24		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	116.55							Fee Schedule		959.46							Fee Schedule		580.58							Fee Schedule		931.51							Fee Schedule		141.75							Fee Schedule		1071.24							Fee Schedule		866.3							Fee Schedule											1071.24							Fee Schedule		866.3							Fee Schedule		
KNEE BRACE PULL ON LARGE	274	RC	L1810	CPT				Both			73.5	33.08	33.08	1071.24		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	54.39							Fee Schedule		154.08							Fee Schedule		114.76							Fee Schedule		931.51							Fee Schedule		66.15							Fee Schedule		1071.24							Fee Schedule		866.3							Fee Schedule											1071.24							Fee Schedule		866.3							Fee Schedule		
KNEE BRACE PULL ON MEDIUM	274	RC	L1810	CPT				Both			73.5	33.08	33.08	172.03		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	54.39							Fee Schedule		154.08							Fee Schedule		114.76							Fee Schedule		149.59							Fee Schedule		66.15							Fee Schedule		172.03							Fee Schedule		139.12							Fee Schedule											172.03							Fee Schedule		139.12							Fee Schedule		
KNEE BRACE PULL ON SM.	274	RC	L1810	CPT				Both			73.5	33.08	33.08	172.03		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	54.39							Fee Schedule		154.08							Fee Schedule		114.76							Fee Schedule		149.59							Fee Schedule		66.15							Fee Schedule		172.03							Fee Schedule		139.12							Fee Schedule											172.03							Fee Schedule		139.12							Fee Schedule		
KNEE BTACE POST-OP 11-2151-9	274	RC	L1832	CPT				Both			330	148.5	139.12	959.46		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	244.2							Fee Schedule		959.46							Fee Schedule		580.58							Fee Schedule		149.59							Fee Schedule		297							Fee Schedule		172.03							Fee Schedule		139.12							Fee Schedule											172.03							Fee Schedule		139.12							Fee Schedule		
KNEE HIGH LEG COVERS #8458	271	RC						Both			3	1.35	1.35	1071.24	1.95							Fee Schedule		2.22							Fee Schedule																				931.51							Fee Schedule		2.7							Fee Schedule		1071.24							Fee Schedule		866.3							Fee Schedule											1071.24							Fee Schedule		866.3							Fee Schedule		
KNEE IMMOBILIZER LARGE 20  #79-80027	274	RC						Both			38	17.1	17.1	34.2		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	28.12							Fee Schedule																													34.2							Fee Schedule																																															
KNEE IMMOBILIZER LARGE 24  #79-80037	274	RC						Both			44	19.8	19.8	39.6		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	32.56							Fee Schedule																													39.6							Fee Schedule																																															
KNEE IMMOBILIZER MEDIUM 20  #79-80025	270	RC						Both			38	17.1	17.1	34.2	24.7							Fee Schedule		28.12							Fee Schedule																													34.2							Fee Schedule																																															
KNEE IMMOBILIZER MEDIUM 24  #79-80035	274	RC						Both			44	19.8	19.8	39.6		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	32.56							Fee Schedule																													39.6							Fee Schedule																																															
KNEE IMMOBILIZER SMALL 20  #79-80023	274	RC						Both			38	17.1	17.1	34.2		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	28.12							Fee Schedule																													34.2							Fee Schedule																																															
KNEE IMMOBILIZER SMALL 24  #79-80033	274	RC						Both			42	18.9	18.9	37.8		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	31.08							Fee Schedule																													37.8							Fee Schedule																																															
KNEE IMMOBILIZER X-LARGE 20  #79-80028	270	RC						Both			38	17.1	17.1	34.2	24.7							Fee Schedule		28.12							Fee Schedule																													34.2							Fee Schedule																																															
KNEE IMMOBILIZER X-LARGE 24  #79-80038	274	RC						Both			44	19.8	19.8	39.6		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	32.56							Fee Schedule																													39.6							Fee Schedule																																															
KNEE LT 3V	320	RC	73562	CPT				Both			315	141.75	16.3	318	21.42							Fee Schedule		25.19							Fee Schedule											16.3							Fee Schedule											283.5							Fee Schedule																				318							Per Diem																				
KNEE LT 3V W/STAND	320	RC	73562	CPT				Both			315	141.75	16.3	318	21.42							Fee Schedule		25.19							Fee Schedule											16.3							Fee Schedule											283.5							Fee Schedule																				318							Per Diem																				
KNEE LT 4 VIEW	320	RC	73564	CPT				Both			315	141.75	17.71	318	23.17							Fee Schedule		27.47							Fee Schedule											17.71							Fee Schedule											283.5							Fee Schedule																				318							Per Diem																				
KNEE PACK TOTAL #DYNJS3013	272	RC						Both			207	93.15	93.15	186.3	134.55							Fee Schedule		153.18							Fee Schedule																													186.3							Fee Schedule																																															
HEPATOBILIARY DIAGNOSTIC PROCEDURES WITH CC					421	DRG		Inpatient			75500.32	33975.14	33975.14	33975.14							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period	
KNEE RT 3V	320	RC	73562	CPT				Both			315	141.75	16.3	318	21.42							Fee Schedule		25.19							Fee Schedule											16.3							Fee Schedule											283.5							Fee Schedule																				318							Per Diem																				
KNEE RT 3V W/STANDING	320	RC	73562	CPT				Both			315	141.75	16.3	318	21.42							Fee Schedule		25.19							Fee Schedule											16.3							Fee Schedule											283.5							Fee Schedule																				318							Per Diem																				
KNEE RT 4V	320	RC	73564	CPT				Both			315	141.75	17.71	318	23.17							Fee Schedule		27.47							Fee Schedule											17.71							Fee Schedule											283.5							Fee Schedule																				318							Per Diem																				
KNEE STANDING AP	320	RC	73565	CPT				Both			315	141.75	14.21	318	22							Fee Schedule		25.84							Fee Schedule											14.21							Fee Schedule											283.5							Fee Schedule																				318							Per Diem																				
KNIFE ELECTRODE	272	RC						Both			252	113.4	113.4	226.8	163.8							Fee Schedule		186.48							Fee Schedule																													226.8							Fee Schedule																																															
KNIFE HANDLE N0522	272	RC						Both			24	10.8	10.8	21.6	15.6							Fee Schedule		17.76							Fee Schedule																													21.6							Fee Schedule																																															
KNUCKLE BENDER	270	RC						Both			21.89	9.85	9.85	19.7	14.23							Fee Schedule		16.2							Fee Schedule																													19.7							Fee Schedule																																															
KNUCKLE BENDER	270	RC						Both			24.15	10.87	10.87	21.74	15.7							Fee Schedule		17.87							Fee Schedule																													21.74							Fee Schedule																																															
KOH PREP TO REF LAB 4605	306	RC	87220	CPT				Both			60.9	27.41	3.79	54.81	3.79							Fee Schedule		4.75							Fee Schedule		4.4							Fee Schedule		4.27							Fee Schedule											54.81							Fee Schedule																				4.27							Fee Schedule																				
KONSYL	250	RC	A9270	CPT				Both			4.2	1.89	0.01	4.91	0.01							Fee Schedule		3.11							Fee Schedule																				4.27							Fee Schedule		3.78							Fee Schedule		4.91							Fee Schedule		3.97							Fee Schedule											4.91							Fee Schedule		3.97							Fee Schedule		
KOOLIT GEL PACKS (VWR)	270	RC						Both			3.15	1.42	1.42	2.84	2.05							Fee Schedule		2.33							Fee Schedule																													2.84							Fee Schedule																																															
KOPANS HOOK WIRE 21G-5CM	272	RC						Both			74	33.3	33.3	66.6	48.1							Fee Schedule		54.76							Fee Schedule																													66.6							Fee Schedule																																															
KOPANS HOOK WIRE 21GX7CM #G03507	272	RC	C1751	CPT				Both			78	35.1	35.1	70.2	69.11							Fee Schedule		57.72							Fee Schedule																													70.2							Fee Schedule																																															
KOPANS NEEDLE 20GX7CM #G02601 (IZI)	272	RC	C1751	CPT				Both			78	35.1	35.1	70.2	69.11							Fee Schedule		57.72							Fee Schedule																													70.2							Fee Schedule																																															
KOPANS NEEDLE DKBL-20-9.0-A ( IZI MEDIC	272	RC	C1751	CPT				Both			77	34.65	34.65	69.3	69.11							Fee Schedule		56.98							Fee Schedule																													69.3							Fee Schedule																																															
KOPANS NEEDLE G02900 ( IZI )	272	RC	C1751	CPT				Both			87.15	39.22	39.22	78.44	69.11							Fee Schedule		64.49							Fee Schedule																													78.44							Fee Schedule																																															
K-PHOS NEUTRAL TABS	250	RC	A9270	CPT				Both			5.25	2.36	0.01	4.73	0.01							Fee Schedule		3.89							Fee Schedule																													4.73							Fee Schedule																																															
K-PHOS ORIGINAL 500MG TAB	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
KRYSTEXXA INTRAVENOUS SOLUTION 8MG/1ML	636	RC	J2507	CPT				Both			110674.77	49803.65	3824.52	99607.29		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	3824.52							Fee Schedule		3881.87							Fee Schedule																				99607.29							Fee Schedule																																															
KUTRASE CAPSULE	250	RC	A9270	CPT				Both			5.25	2.36	0.01	4334.13	0.01							Fee Schedule		3.89							Fee Schedule																				3768.81							Fee Schedule		4.73							Fee Schedule		4334.13							Fee Schedule		3504.99							Fee Schedule											4334.13							Fee Schedule		3504.99							Fee Schedule		
KUZYME CAPSULE	250	RC	A9270	CPT				Both			4.2	1.89	0.01	3.78	0.01							Fee Schedule		3.11							Fee Schedule																													3.78							Fee Schedule																																															
KWELL SHAMPOO 60 ML	250	RC	A9270	CPT				Both			13.65	6.14	0.01	12.29	0.01							Fee Schedule		10.1							Fee Schedule																													12.29							Fee Schedule																																															
KY JELLY 3-GRAM PACK MEDLINE	272	RC	A4332	CPT				Both			1	0.45	0.1	0.9	0.1							Fee Schedule		0.74							Fee Schedule		0.15							Fee Schedule																				0.9							Fee Schedule																																															
KY JELLY 4OZ TUBES #MDS032290Z MEDLINE	272	RC	A4332	CPT				Both			3	1.35	0.1	2.7	0.1							Fee Schedule		2.22							Fee Schedule		0.15							Fee Schedule											0.15							Fee Schedule		2.7							Fee Schedule		0.17							Fee Schedule		0.14							Fee Schedule											0.17							Fee Schedule		0.14							Fee Schedule		
K-Y JELLY LARGE TUBE	272	RC						Both			3.15	1.42	0.14	2.84	2.05							Fee Schedule		2.33							Fee Schedule																				0.15							Fee Schedule		2.84							Fee Schedule		0.17							Fee Schedule		0.14							Fee Schedule											0.17							Fee Schedule		0.14							Fee Schedule		
KYTRIL 1 MG/ML 4MLVIAL	636	RC	S0091	CPT				Both			669.9	301.46	301.46	602.91		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	495.73							Fee Schedule																													602.91							Fee Schedule																																															
L T A KIT	272	RC						Both			46.2	20.79	20.79	41.58	30.03							Fee Schedule		34.19							Fee Schedule																													41.58							Fee Schedule																																															
L.E.T. TOPICAL SOLUTION 3ML SYRINGE	250	RC	A9270	CPT				Both			31.5	14.18	0.01	28.35	0.01							Fee Schedule		23.31							Fee Schedule																													28.35							Fee Schedule																																															
LABELS UNIT DOSE FOR PHARM. 7261	270	RC						Both			156	70.2	70.2	140.4	101.4							Fee Schedule		115.44							Fee Schedule																													140.4							Fee Schedule																																															
LABETALOL  5 MG/ML-20ML VIAL	250	RC	J1920	CPT				Both			12.6	5.67	0.22	11.34	8.19							Fee Schedule		9.32							Fee Schedule		0.22							Fee Schedule																				11.34							Fee Schedule																																															
LABETALOL  5 MG/ML-40 ML VIAL	250	RC	J1920	CPT				Both			12.6	5.67	0.2	11.34	8.19							Fee Schedule		9.32							Fee Schedule		0.22							Fee Schedule											0.22							Fee Schedule		11.34							Fee Schedule		0.25							Fee Schedule		0.2							Fee Schedule											0.25							Fee Schedule		0.2							Fee Schedule		
LABETALOL 100 MG TABLET UD	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																				0.22							Fee Schedule		5.67							Fee Schedule		0.25							Fee Schedule		0.2							Fee Schedule											0.25							Fee Schedule		0.2							Fee Schedule		
LABETALOL 5MG/ML-4ML SDV	250	RC	J1920	CPT				Both			15.18	6.83	0.22	13.66	9.87							Fee Schedule		11.23							Fee Schedule		0.22							Fee Schedule																				13.66							Fee Schedule																																															
LABETALOL STANDARD DRIP	250	RC	J1920	CPT				Both			31.5	14.18	0.2	28.35	20.48							Fee Schedule		23.31							Fee Schedule		0.22							Fee Schedule											0.22							Fee Schedule		28.35							Fee Schedule		0.25							Fee Schedule		0.2							Fee Schedule											0.25							Fee Schedule		0.2							Fee Schedule		
LABOR PROGRESS SHEET (BRIGGS)	271	RC						Both			22.05	9.92	0.2	19.85	14.33							Fee Schedule		16.32							Fee Schedule																				0.22							Fee Schedule		19.85							Fee Schedule		0.25							Fee Schedule		0.2							Fee Schedule											0.25							Fee Schedule		0.2							Fee Schedule		
LACOSAMIDE 16262 SERUM	301	RC	80299	CPT				Both			131.25	59.06	13.42	118.13	13.42							Fee Schedule		18.64							Fee Schedule		19.2							Fee Schedule		18.64							Fee Schedule											118.13							Fee Schedule																				18.64							Fee Schedule																				
LACRI LUBE	250	RC	A9270	CPT				Both			31.53	14.19	0.01	28.38	0.01							Fee Schedule		23.33							Fee Schedule																				18.64							Fee Schedule		28.38							Fee Schedule		21.44							Fee Schedule		17.34							Fee Schedule											21.44							Fee Schedule		17.34							Fee Schedule		
LACTIC ACID FLUID 1659	301	RC	83605	CPT				Both			106.05	47.72	9.5	95.45	9.5							Fee Schedule		11.87							Fee Schedule		11.92							Fee Schedule		11.57							Fee Schedule											95.45							Fee Schedule																																															
LACTIC ACID GRAY TOP TUBE ON ICE	301	RC	83605	CPT				Both			57.75	25.99	9.5	51.98	9.5							Fee Schedule		11.87							Fee Schedule		11.92							Fee Schedule		11.57							Fee Schedule		11.57							Fee Schedule		51.98							Fee Schedule		13.31							Fee Schedule		10.76							Fee Schedule											13.31							Fee Schedule		10.76							Fee Schedule		
LACTOBACILLUS GRANULES PACKETTE UD- 12	250	RC	A9270	CPT				Both			6.3	2.84	0.01	13.31	0.01							Fee Schedule		4.66							Fee Schedule																				11.57							Fee Schedule		5.67							Fee Schedule		13.31							Fee Schedule		10.76							Fee Schedule											13.31							Fee Schedule		10.76							Fee Schedule		
LACTULOSE 20 GM/30ML SOLUTION UD	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
LACTULOSE SOL 10GM/15ML(RECTAL) 946ML	250	RC	A9270	CPT				Both			173.88	78.25	0.01	156.49	0.01							Fee Schedule		128.67							Fee Schedule																													156.49							Fee Schedule																																															
LAG SCREW LARGE 85MM	278	RC						Both			303.45	136.55	136.55	273.11		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	224.55							Fee Schedule																													273.11							Fee Schedule																																															
LAMOTRIGINE  25MG (LAMICTAL) TABLET	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
LAMOTRIGINE 100MG (LAMICTAL) TABLET	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
LAMOTRIGINE 22060 SERUM  LAMICTAL	300	RC	80175	CPT				Both			144.9	65.21	11.78	130.41	11.78							Fee Schedule		14.73							Fee Schedule		13.65							Fee Schedule		13.25							Fee Schedule											130.41							Fee Schedule																				13.25							Fee Schedule																				
LANSINOH BREAST FEED OINT -7GM	250	RC	A9270	CPT				Both			8.4	3.78	0.01	15.24	0.01							Fee Schedule		6.22							Fee Schedule																				13.25							Fee Schedule		7.56							Fee Schedule		15.24							Fee Schedule		12.32							Fee Schedule											15.24							Fee Schedule		12.32							Fee Schedule		
LANSOPRAZOLE 30 MG INJECTION	250	RC						Both			92.4	41.58	41.58	83.16	60.06							Fee Schedule		68.38							Fee Schedule																													83.16							Fee Schedule																																															
LANTUS SOLOSTAR PEN	250	RC	J1815	CPT				Both			127.63	57.43	0.9	114.87	0.9							Fee Schedule		94.45							Fee Schedule																													114.87							Fee Schedule																																															
LAP CHOLE DRAPE #DYNJP3102A	272	RC						Both			31	13.95	13.95	27.9	20.15							Fee Schedule		22.94							Fee Schedule																													27.9							Fee Schedule																																															
LAP CHOLE KIT 00C6111	272	RC						Both			570.15	256.57	256.57	513.14	370.6							Fee Schedule		421.91							Fee Schedule																													513.14							Fee Schedule																																															
LAP PACK OBT261D (MEDLINE)	272	RC						Both			92	41.4	41.4	82.8	59.8							Fee Schedule		68.08							Fee Schedule																													82.8							Fee Schedule																																															
LAP SPONGE COUNTERS 25-500 DEROYAL	271	RC						Both			4.2	1.89	1.89	3.78	2.73							Fee Schedule		3.11							Fee Schedule																													3.78							Fee Schedule																																															
LAP SPONGES #MDS251518LF	272	RC						Both			21	9.45	9.45	18.9	13.65							Fee Schedule		15.54							Fee Schedule																													18.9							Fee Schedule																																															
LAP TRAY	272	RC						Both			68.25	30.71	30.71	61.43	44.36							Fee Schedule		50.51							Fee Schedule																													61.43							Fee Schedule																																															
LAP WIRE HOOK ELECTRODE #E3773-36C	272	RC						Both			350	157.5	157.5	315	227.5							Fee Schedule		259							Fee Schedule																													315							Fee Schedule																																															
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH MCC					432	DRG		Inpatient			39451.9	17753.36	17753.36	17753.36							0		No services performed during 15 month lookback period. 				4521.3	4521.3	4521.3	1 through 10						16156.18	16156.18	16156.18	1 through 10									0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period				7007.44	7007.44	7007.44	1 through 10									0		No services provided during 15 month lookback							0		No services provided during 15 month lookback period				2616.07	2616.07	2616.07	1 through 10			
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH CC					433	DRG		Inpatient			29448.15	13251.67	13251.67	13251.67							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period	
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITHOUT CC/MCC					434	DRG		Inpatient			17337.2	7801.74	7801.74	7801.74							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period	
LAPAROSCOPIC CLOSURE DEVICE PMITCSG	272	RC						Both			136	61.2	61.2	122.4	88.4							Fee Schedule		100.64							Fee Schedule																													122.4							Fee Schedule																																															
LAPROSCOPIC L-HOOK	272	RC						Both			263.55	118.6	118.6	237.2	171.31							Fee Schedule		195.03							Fee Schedule																													237.2							Fee Schedule																																															
LAPS 12X12	272	RC						Both			13.65	6.14	6.14	12.29	8.87							Fee Schedule		10.1							Fee Schedule																													12.29							Fee Schedule																																															
LARGE TEAR RASP	272	RC						Both			403.2	181.44	181.44	362.88	262.08							Fee Schedule		298.37							Fee Schedule																													362.88							Fee Schedule																																															
L-ARGININE 500 MG TABLET UD	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
LARYN. BLADE DISP. MAC SIZE 0 #ML19704	272	RC						Both			18	8.1	8.1	16.2	11.7							Fee Schedule		13.32							Fee Schedule																													16.2							Fee Schedule																																															
LARYN. BLADE DISP. MILLER SZ 00 #ML19710	272	RC						Both			18	8.1	8.1	16.2	11.7							Fee Schedule		13.32							Fee Schedule																													16.2							Fee Schedule																																															
LARYNGEAL ELECTRODE 6-7MM #5140-530-855	272	RC						Both			600	270	270	540	390							Fee Schedule		444							Fee Schedule																													540							Fee Schedule																																															
LARYNGEAL ELECTRODE 7-9MM #5140-530-856	272	RC						Both			600	270	270	540	390							Fee Schedule		444							Fee Schedule																													540							Fee Schedule																																															
LARYNGEAL TRAC TUBE 8.0 MALLINKRODT	272	RC						Both			44.1	19.85	19.85	39.69	28.67							Fee Schedule		32.63							Fee Schedule																													39.69							Fee Schedule																																															
LARYNGECTOMY TUBE JACKSON #10	272	RC	A7522	CPT				Both			376.95	169.63	39.35	339.26	40.66							Fee Schedule		278.94							Fee Schedule		66.29							Fee Schedule		39.35							Fee Schedule											339.26							Fee Schedule																																															
LARYNGECTOMY TUBE JACKSON #12	272	RC	A7522	CPT				Both			380.1	171.05	39.35	342.09	40.66							Fee Schedule		281.27							Fee Schedule		66.29							Fee Schedule		39.35							Fee Schedule		64.36							Fee Schedule		342.09							Fee Schedule		74.01							Fee Schedule		59.85							Fee Schedule											74.01							Fee Schedule		59.85							Fee Schedule		
LARYNGOSCOPE BLADE DISP.  MAC SIZE 1	272	RC						Both			18	8.1	8.1	74.01	11.7							Fee Schedule		13.32							Fee Schedule																				64.36							Fee Schedule		16.2							Fee Schedule		74.01							Fee Schedule		59.85							Fee Schedule											74.01							Fee Schedule		59.85							Fee Schedule		
LARYNGOSCOPE BLADE DISP.  MAC SIZE 2	272	RC						Both			20	9	9	18	13							Fee Schedule		14.8							Fee Schedule																													18							Fee Schedule																																															
LARYNGOSCOPE BLADE DISP.  MAC SIZE 3	272	RC						Both			13	5.85	5.85	11.7	8.45							Fee Schedule		9.62							Fee Schedule																													11.7							Fee Schedule																																															
LARYNGOSCOPE BLADE DISP.  MAC SIZE 4	272	RC						Both			15	6.75	6.75	13.5	9.75							Fee Schedule		11.1							Fee Schedule																													13.5							Fee Schedule																																															
LARYNGOSCOPE BLADE DISP.  MILLER SIZE 0	272	RC						Both			11	4.95	4.95	9.9	7.15							Fee Schedule		8.14							Fee Schedule																													9.9							Fee Schedule																																															
LARYNGOSCOPE BLADE DISP.  MILLER SIZE 1	272	RC						Both			11	4.95	4.95	9.9	7.15							Fee Schedule		8.14							Fee Schedule																													9.9							Fee Schedule																																															
LARYNGOSCOPE BLADE DISP.  MILLER SIZE 2	272	RC						Both			11	4.95	4.95	9.9	7.15							Fee Schedule		8.14							Fee Schedule																													9.9							Fee Schedule																																															
LARYNGOSCOPE BLADE DISP.  MILLER SIZE 3	272	RC						Both			11	4.95	4.95	9.9	7.15							Fee Schedule		8.14							Fee Schedule																													9.9							Fee Schedule																																															
LARYNGOSCOPE BLADE DISP.  MILLER SIZE 4	272	RC						Both			11	4.95	4.95	9.9	7.15							Fee Schedule		8.14							Fee Schedule																													9.9							Fee Schedule																																															
LARYNGOSCOPE HANDLE DISP. 301-FO-S	272	RC						Both			17	7.65	7.65	15.3	11.05							Fee Schedule		12.58							Fee Schedule																													15.3							Fee Schedule																																															
LATANOPROST(XALATAN 0.005%) OPTH -2.5ML	250	RC	A9270	CPT				Both			60.9	27.41	0.01	54.81	0.01							Fee Schedule		45.07							Fee Schedule																													54.81							Fee Schedule																																															
LATCHASSIST 70170	270	RC						Both			19	8.55	8.55	17.1	12.35							Fee Schedule		14.06							Fee Schedule																													17.1							Fee Schedule																																															
LATERAL POSITION PILLOW SH18436  SHARN	271	RC						Both			92	41.4	41.4	82.8	59.8							Fee Schedule		68.08							Fee Schedule																													82.8							Fee Schedule																																															
LATERAL POSTIONER PILLOW SH-18436	271	RC						Both			92	41.4	41.4	82.8	59.8							Fee Schedule		68.08							Fee Schedule																													82.8							Fee Schedule																																															
LAURUS NEEDLE DRIVER	272	RC						Both			275.1	123.8	123.8	247.59	178.82							Fee Schedule		203.57							Fee Schedule																													247.59							Fee Schedule																																															
LAVACUATOR TUBE	272	RC						Both			30.45	13.7	13.7	27.41	19.79							Fee Schedule		22.53							Fee Schedule																													27.41							Fee Schedule																																															
LAVH PACK #DYNJP9120A	272	RC						Both			86	38.7	38.7	77.4	55.9							Fee Schedule		63.64							Fee Schedule																													77.4							Fee Schedule																																															
LAVH PACK DYNJP9120A MEDLINE	270	RC						Both			86	38.7	38.7	77.4	55.9							Fee Schedule		63.64							Fee Schedule																													77.4							Fee Schedule																																															
LDH	301	RC	83615	CPT				Both			85.05	38.27	5.36	76.55	5.36							Fee Schedule		6.71							Fee Schedule		6.22							Fee Schedule		6.04							Fee Schedule											76.55							Fee Schedule																				6.04							Fee Schedule																				
LDH CSF  1 ML FLUID	301	RC	83615	CPT				Both			22.05	9.92	5.36	19.85	5.36							Fee Schedule		6.71							Fee Schedule		6.22							Fee Schedule		6.04							Fee Schedule		6.04							Fee Schedule		19.85							Fee Schedule		6.95							Fee Schedule		5.62							Fee Schedule		6.04							Fee Schedule		6.95							Fee Schedule		5.62							Fee Schedule		
LDH ISOENZYMES 597	301	RC	83625	CPT				Both			55.65	25.04	5.62	50.09	11.38							Fee Schedule		14.22							Fee Schedule		13.17							Fee Schedule		12.79							Fee Schedule		6.04							Fee Schedule		50.09							Fee Schedule		6.95							Fee Schedule		5.62							Fee Schedule		12.79							Fee Schedule		6.95							Fee Schedule		5.62							Fee Schedule		
"LDH, CSF QUEST 1687"	301	RC	83615	CPT				Both			11.16	5.02	5.02	14.71	5.36							Fee Schedule		6.71							Fee Schedule		6.22							Fee Schedule		6.04							Fee Schedule		12.79							Fee Schedule		10.04							Fee Schedule		14.71							Fee Schedule		11.89							Fee Schedule		6.04							Fee Schedule		14.71							Fee Schedule		11.89							Fee Schedule		
"LDH, PERICARDIAL FLUID QUEST 17647"	301	RC	83615	CPT				Both			11.16	5.02	5.02	10.04	5.36							Fee Schedule		6.71							Fee Schedule		6.22							Fee Schedule		6.04							Fee Schedule		6.04							Fee Schedule		10.04							Fee Schedule		6.95							Fee Schedule		5.62							Fee Schedule		6.04							Fee Schedule		6.95							Fee Schedule		5.62							Fee Schedule		
"LDH, PERITONEAL FLUID QUEST 17588"	301	RC	83615	CPT				Both			11.16	5.02	5.02	10.04	5.36							Fee Schedule		6.71							Fee Schedule		6.22							Fee Schedule		6.04							Fee Schedule		6.04							Fee Schedule		10.04							Fee Schedule		6.95							Fee Schedule		5.62							Fee Schedule		6.04							Fee Schedule		6.95							Fee Schedule		5.62							Fee Schedule		
"LDH, PLEURAL FLUID QUEST 17589"	301	RC	83615	CPT				Both			11.16	5.02	5.02	10.04	5.36							Fee Schedule		6.71							Fee Schedule		6.22							Fee Schedule		6.04							Fee Schedule		6.04							Fee Schedule		10.04							Fee Schedule		6.95							Fee Schedule		5.62							Fee Schedule		6.04							Fee Schedule		6.95							Fee Schedule		5.62							Fee Schedule		
"LDH, SYNOVIAL FLUID QUEST 17658"	301	RC	83615	CPT				Both			11.16	5.02	5.02	10.04	5.36							Fee Schedule		6.71							Fee Schedule		6.22							Fee Schedule		6.04							Fee Schedule		6.04							Fee Schedule		10.04							Fee Schedule		6.95							Fee Schedule		5.62							Fee Schedule		6.04							Fee Schedule		6.95							Fee Schedule		5.62							Fee Schedule		
LEAD LEV BLD 3058 INDUSTRIAL LEVEL	301	RC	83655	CPT				Both			115.5	51.98	5.62	103.95	10.76							Fee Schedule		13.45							Fee Schedule		12.47							Fee Schedule		12.11							Fee Schedule		6.04							Fee Schedule		103.95							Fee Schedule		6.95							Fee Schedule		5.62							Fee Schedule		12.11							Fee Schedule		6.95							Fee Schedule		5.62							Fee Schedule		
LEAD LEV BLD 599	301	RC	83655	CPT				Both			68.25	30.71	10.76	61.43	10.76							Fee Schedule		13.45							Fee Schedule		12.47							Fee Schedule		12.11							Fee Schedule		12.11							Fee Schedule		61.43							Fee Schedule		13.93							Fee Schedule		11.26							Fee Schedule		12.11							Fee Schedule		13.93							Fee Schedule		11.26							Fee Schedule		
LEAD LEV CAPILLARY BLOOD 39027 0.5 ML	301	RC	83655	CPT				Both			68.25	30.71	10.76	61.43	10.76							Fee Schedule		13.45							Fee Schedule		12.47							Fee Schedule		12.11							Fee Schedule		12.11							Fee Schedule		61.43							Fee Schedule		13.93							Fee Schedule		11.26							Fee Schedule		12.11							Fee Schedule		13.93							Fee Schedule		11.26							Fee Schedule		
LEATHER LYCA W/C GLOVES	274	RC	L3984	CPT				Both			61.95	27.88	11.26	472.19		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	45.84							Fee Schedule		472.19							Fee Schedule		329.1							Fee Schedule		12.11							Fee Schedule		55.76							Fee Schedule		13.93							Fee Schedule		11.26							Fee Schedule											13.93							Fee Schedule		11.26							Fee Schedule		
LEFLUNOMIDE 20MG (ARAVA) TABLET	250	RC	A9270	CPT				Both			56.7	25.52	0.01	527.21	0.01							Fee Schedule		41.96							Fee Schedule																				458.44							Fee Schedule		51.03							Fee Schedule		527.21							Fee Schedule		426.35							Fee Schedule											527.21							Fee Schedule		426.35							Fee Schedule		
LEG BAG #150102	270	RC	A4358	CPT				Both			6	2.7	2.7	8.28	5.07							Fee Schedule		4.44							Fee Schedule		8.28							Fee Schedule		6.34							Fee Schedule											5.4							Fee Schedule																																															
LEGIONELLA AG 8856 URINE BY RIA	306	RC	87449	CPT				Both			150.15	67.57	7.48	135.14	10.66							Fee Schedule		13.32							Fee Schedule		12.34							Fee Schedule		11.98							Fee Schedule		8.04							Fee Schedule		135.14							Fee Schedule		9.25							Fee Schedule		7.48							Fee Schedule		11.98							Fee Schedule		9.25							Fee Schedule		7.48							Fee Schedule		
LEGIONELLA PNEUMOPHILA IGG 36580  2ML SR	302	RC	86713	CPT				Both			249.9	112.46	11.14	224.91	13.6							Fee Schedule		17							Fee Schedule		15.76							Fee Schedule		15.3							Fee Schedule		11.98							Fee Schedule		224.91							Fee Schedule		13.78							Fee Schedule		11.14							Fee Schedule		15.3							Fee Schedule		13.78							Fee Schedule		11.14							Fee Schedule		
LEMAITRE EMBOLECTOMY CATH 3FR #E1651-38	272	RC	C1757	CPT				Both			357	160.65	14.23	321.3	16.33							Fee Schedule		264.18							Fee Schedule																				15.3							Fee Schedule		321.3							Fee Schedule		17.6							Fee Schedule		14.23							Fee Schedule											17.6							Fee Schedule		14.23							Fee Schedule		
LEMAITRE EMBOLECTOMY CATH 4FR #E1601-48	272	RC	C1757	CPT				Both			222	99.9	16.33	199.8	16.33							Fee Schedule		164.28							Fee Schedule																													199.8							Fee Schedule																																															
LEMAITRE EMBOLECTOMY CATH 5FR #E1601-58	272	RC	C1757	CPT				Both			222	99.9	16.33	199.8	16.33							Fee Schedule		164.28							Fee Schedule																													199.8							Fee Schedule																																															
LEPTIN 90367 1ML SERUM REFRIG	301	RC	80299	CPT				Both			220.5	99.23	13.42	198.45	13.42							Fee Schedule		18.64							Fee Schedule		19.2							Fee Schedule		18.64							Fee Schedule											198.45							Fee Schedule																				18.64							Fee Schedule																				
LEPTOSPIRA AB 17875 1ML WHOLE BLD LAV TU	302	RC	87798	CPT				Both			382.2	171.99	17.34	343.98	31.2							Fee Schedule		38.99							Fee Schedule		36.14							Fee Schedule		35.09							Fee Schedule		18.64							Fee Schedule		343.98							Fee Schedule		21.44							Fee Schedule		17.34							Fee Schedule		35.09							Fee Schedule		21.44							Fee Schedule		17.34							Fee Schedule		
LEQVIO 284MG/1.5ML SYRINGE	636	RC	J1306	CPT				Both			12144.27	5464.92	12.61	10929.84		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	12.61							Fee Schedule		13.07							Fee Schedule											35.09							Fee Schedule		10929.84							Fee Schedule		40.35							Fee Schedule		32.63							Fee Schedule											40.35							Fee Schedule		32.63							Fee Schedule		
LESCOL 20 MG (FLUVASTATIN) CAPSULE	250	RC	A9270	CPT				Both			10.62	4.78	0.01	14.59	0.01							Fee Schedule		7.86							Fee Schedule																				12.69							Fee Schedule		9.56							Fee Schedule		14.59							Fee Schedule		11.8							Fee Schedule											14.59							Fee Schedule		11.8							Fee Schedule		
LESCOL 40 MG CAPSULE UD	250	RC	A9270	CPT				Both			4.44	2	0.01	4	0.01							Fee Schedule		3.29							Fee Schedule																													4							Fee Schedule																																															
LEUCOVORIN 5 MG TABS	636	RC	J0640	CPT				Both			11.55	5.2	3.02	26.12		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	8.55							Fee Schedule		3.02							Fee Schedule		26.12							Fee Schedule											10.4							Fee Schedule																																															
LEUCOVORIN CALCIUM 50MG INJECTION	636	RC	J0640	CPT				Both			37.8	17.01	2.73	34.02		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	27.97							Fee Schedule		3.02							Fee Schedule		26.12							Fee Schedule		2.93							Fee Schedule		34.02							Fee Schedule		3.37							Fee Schedule		2.73							Fee Schedule											3.37							Fee Schedule		2.73							Fee Schedule		
LEUKINE 500 MCG/ML 5 ML/MDV	636	RC	J2820	CPT				Both			926.1	416.75	2.73	833.49		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	61.88							Fee Schedule		63.6							Fee Schedule		30.28							Fee Schedule		2.93							Fee Schedule		833.49							Fee Schedule		3.37							Fee Schedule		2.73							Fee Schedule											3.37							Fee Schedule		2.73							Fee Schedule		
"LEUKOTRIENE E4, RAND, UR 11985"	301	RC	82542	CPT				Both			900	405	17.34	810	17.34							Fee Schedule		24.09							Fee Schedule		24.81							Fee Schedule		24.09							Fee Schedule		61.75							Fee Schedule		810							Fee Schedule		71.01							Fee Schedule		57.42							Fee Schedule		24.09							Fee Schedule		71.01							Fee Schedule		57.42							Fee Schedule		
LEVAQUIN 500 MG VIAL (25 MG/ML)20 ML	636	RC	J1956	CPT				Both			136.5	61.43	1.97	122.85		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	101.01							Fee Schedule		1.97							Fee Schedule											24.09							Fee Schedule		122.85							Fee Schedule		27.7							Fee Schedule		22.4							Fee Schedule											27.7							Fee Schedule		22.4							Fee Schedule		
LEVER LOCK CANNULA	270	RC						Both			3.15	1.42	1.42	2.84	2.05							Fee Schedule		2.33							Fee Schedule																				1.91							Fee Schedule		2.84							Fee Schedule		2.2							Fee Schedule		1.78							Fee Schedule											2.2							Fee Schedule		1.78							Fee Schedule		
LEVERLOCK ADPTR PLUG	272	RC						Both			1.58	0.71	0.71	1.42	1.03							Fee Schedule		1.17							Fee Schedule																													1.42							Fee Schedule																																															
LEVETIRACETAM 1000MG/100 ML PREMIX	636	RC	J1953	CPT				Both			187.95	84.58	0.03	169.16		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	139.08							Fee Schedule		0.03							Fee Schedule																				169.16							Fee Schedule																																															
LEVETIRACETAM 1500MG/100 ML PREMIX	636	RC	J1953	CPT				Both			280.35	126.16	0.03	252.32		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	207.46							Fee Schedule		0.03							Fee Schedule											0.03							Fee Schedule		252.32							Fee Schedule		0.04							Fee Schedule		0.03							Fee Schedule											0.04							Fee Schedule		0.03							Fee Schedule		
LEVETIRACETAM 250 MG (KEPPRA) TABLET	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																				0.03							Fee Schedule		5.67							Fee Schedule		0.04							Fee Schedule		0.03							Fee Schedule											0.04							Fee Schedule		0.03							Fee Schedule		
LEVETIRACETAM 500 MG (KEPPRA) TABLET	250	RC	A9270	CPT				Both			8.4	3.78	0.01	7.56	0.01							Fee Schedule		6.22							Fee Schedule																													7.56							Fee Schedule																																															
LEVETIRACETAM 500MG/100 ML PREMIX	636	RC	J1953	CPT				Both			112.35	50.56	0.03	101.12		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	83.14							Fee Schedule		0.03							Fee Schedule																				101.12							Fee Schedule																																															
LEVETIRACETAM 500MG/5ML VIAL	636	RC	J1953	CPT				Both			31.5	14.18	0.03	28.35		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	23.31							Fee Schedule		0.03							Fee Schedule											0.03							Fee Schedule		28.35							Fee Schedule		0.04							Fee Schedule		0.03							Fee Schedule											0.04							Fee Schedule		0.03							Fee Schedule		
"LEVETIRACETAM, IMMUNOASSAY 36330"	301	RC	80177	CPT				Both			175.35	78.91	0.03	157.82	11.78							Fee Schedule		14.73							Fee Schedule		13.65							Fee Schedule		13.25							Fee Schedule		0.03							Fee Schedule		157.82							Fee Schedule		0.04							Fee Schedule		0.03							Fee Schedule		13.25							Fee Schedule		0.04							Fee Schedule		0.03							Fee Schedule		
LEVINE TUBE 10 FR #8888264911	272	RC	B4083	CPT				Both			3	1.35	0.91	15.24	0.91							Fee Schedule		2.22							Fee Schedule											3.05							Fee Schedule		13.25							Fee Schedule		2.7							Fee Schedule		15.24							Fee Schedule		12.32							Fee Schedule											15.24							Fee Schedule		12.32							Fee Schedule		
LEVINE TUBE 14 FR #8888264945	270	RC						Both			3	1.35	1.35	2.7	1.95							Fee Schedule		2.22							Fee Schedule																													2.7							Fee Schedule																																															
LEVINE TUBE 16 FR #8888264960	270	RC						Both			3	1.35	1.35	2.7	1.95							Fee Schedule		2.22							Fee Schedule																													2.7							Fee Schedule																																															
LEVINE TUBE 18 FR #8888264986	272	RC						Both			3	1.35	1.35	2.7	1.95							Fee Schedule		2.22							Fee Schedule																													2.7							Fee Schedule																																															
LEVINE TUBE 8 FR #8888268086	272	RC	B4083	CPT				Both			13	5.85	0.91	11.7	0.91							Fee Schedule		9.62							Fee Schedule											3.05							Fee Schedule											11.7							Fee Schedule																																															
LEVINE TUBES	272	RC						Both			7.35	3.31	3.31	6.62	4.78							Fee Schedule		5.44							Fee Schedule																													6.62							Fee Schedule																																															
LEVOBUNOLOL 0.5% OPTH SOL (BETAGAN)-5ML	250	RC	A9270	CPT				Both			52.42	23.59	0.01	47.18	0.01							Fee Schedule		38.79							Fee Schedule																													47.18							Fee Schedule																																															
LEVOFLOXACIN  250 MG/50ML PREMIX IVPB	636	RC	J1956	CPT				Both			17.85	8.03	1.97	16.07		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	13.21							Fee Schedule		1.97							Fee Schedule																				16.07							Fee Schedule																																															
LEVOFLOXACIN  500 MG/100 ML PREMIX IVPB	636	RC	J1956	CPT				Both			26.25	11.81	1.78	23.63		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	19.43							Fee Schedule		1.97							Fee Schedule											1.91							Fee Schedule		23.63							Fee Schedule		2.2							Fee Schedule		1.78							Fee Schedule											2.2							Fee Schedule		1.78							Fee Schedule		
LEVOFLOXACIN  750MG/150ML PREMIX IVPB	636	RC	J1956	CPT				Both			28.35	12.76	1.78	25.52		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	20.98							Fee Schedule		1.97							Fee Schedule											1.91							Fee Schedule		25.52							Fee Schedule		2.2							Fee Schedule		1.78							Fee Schedule											2.2							Fee Schedule		1.78							Fee Schedule		
LEVOFLOXACIN 250MG (LEVAQUIN) TABLET	250	RC	A9270	CPT				Both			46.2	20.79	0.01	41.58	0.01							Fee Schedule		34.19							Fee Schedule																				1.91							Fee Schedule		41.58							Fee Schedule		2.2							Fee Schedule		1.78							Fee Schedule											2.2							Fee Schedule		1.78							Fee Schedule		
LEVOFLOXACIN 500MG (LEVAQUIN) TABLET	250	RC	A9270	CPT				Both			52.5	23.63	0.01	47.25	0.01							Fee Schedule		38.85							Fee Schedule																													47.25							Fee Schedule																																															
LEVOFLOXACIN 750MG (LEVAQUIN) TABLET	250	RC	A9270	CPT				Both			77.7	34.97	0.01	69.93	0.01							Fee Schedule		57.5							Fee Schedule																													69.93							Fee Schedule																																															
LEVOPHED 4MG/4ML VIAL	250	RC	J3490	CPT				Both			68.25	30.71	30.71	61.43	44.36							Fee Schedule		50.51							Fee Schedule																													61.43							Fee Schedule																																															
LEVOPHED 4MG/D5W 500ML DRIP	250	RC	A9270	CPT				Both			80.85	36.38	0.01	72.77	0.01							Fee Schedule		59.83							Fee Schedule																													72.77							Fee Schedule																																															
"LEVOTHROID:0.125 MG (SYNTHROID, LEVOXYL)"	250	RC	A9270	CPT				Both			1.58	0.71	0.01	1.42	0.01							Fee Schedule		1.17							Fee Schedule																													1.42							Fee Schedule																																															
LEVOTHYROXINE  100 MCG/5ML INJECTION	250	RC	J0650	CPT				Both			347.55	156.4	5.25	312.8	225.91							Fee Schedule		257.19							Fee Schedule		5.25							Fee Schedule																				312.8							Fee Schedule																																															
LEVOTHYROXINE  25 MCG TABLET	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.86	0.01							Fee Schedule		4.66							Fee Schedule																				5.1							Fee Schedule		5.67							Fee Schedule		5.86							Fee Schedule		4.74							Fee Schedule											5.86							Fee Schedule		4.74							Fee Schedule		
LEVOTHYROXINE  50 MCG TABLET	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
LEVOTHYROXINE  75 MCG TABLET	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
LEVOTHYROXINE  88 MCG TABLET	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
LEVOTHYROXINE 100 MCG TABLET	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
LEVOTHYROXINE 112 MCG TABLET	250	RC	A9270	CPT				Both			5.25	2.36	0.01	4.73	0.01							Fee Schedule		3.89							Fee Schedule																													4.73							Fee Schedule																																															
LEVOTHYROXINE 125 MCG TABLET	250	RC	A9270	CPT				Both			5.25	2.36	0.01	4.73	0.01							Fee Schedule		3.89							Fee Schedule																													4.73							Fee Schedule																																															
LEVOTHYROXINE 137 MCG TABLET	250	RC	A9270	CPT				Both			6	2.7	0.01	5.4	0.01							Fee Schedule		4.44							Fee Schedule																													5.4							Fee Schedule																																															
LEVOTHYROXINE 150 MCG TABLET	250	RC	A9270	CPT				Both			5.25	2.36	0.01	4.73	0.01							Fee Schedule		3.89							Fee Schedule																													4.73							Fee Schedule																																															
LEVOTHYROXINE 175 MCG TABLET	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
LEVSIN 0.125 MG TAB (HYOSCAMINE)	250	RC	A9270	CPT				Both			5.25	2.36	0.01	4.73	0.01							Fee Schedule		3.89							Fee Schedule																													4.73							Fee Schedule																																															
LEVSIN 0.5 MG/ML (HYOSCYAMINE) INJ	636	RC	J1980	CPT				Both			215.25	96.86	6.22	193.73		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	159.29							Fee Schedule											6.22							Fee Schedule											193.73							Fee Schedule																																															
LEVSIN LIQUID 5ML UD	250	RC	A9270	CPT				Both			7.35	3.31	0.01	6.62	0.01							Fee Schedule		5.44							Fee Schedule																													6.62							Fee Schedule																																															
LEXAPRO (ESCITALOPRAM) 5MG  TABLET	250	RC	A9270	CPT				Both			7.35	3.31	0.01	6.62	0.01							Fee Schedule		5.44							Fee Schedule																													6.62							Fee Schedule																																															
LEXISCAN 0.08 MG/ML 5ML SYR	636	RC	J2785	CPT				Both			874.65	393.59	2.87	787.19		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	647.24							Fee Schedule		2.87							Fee Schedule																				787.19							Fee Schedule																																															
LG CONNECTING TUBING #71-C506	272	RC						Both			2	0.9	0.9	3.21	1.3							Fee Schedule		1.48							Fee Schedule																				2.79							Fee Schedule		1.8							Fee Schedule		3.21							Fee Schedule		2.59							Fee Schedule											3.21							Fee Schedule		2.59							Fee Schedule		
LH LUTEINIZING HORMONE SERUM	301	RC	83002	CPT				Both			354.9	159.71	16.46	319.41	16.46							Fee Schedule		20.57							Fee Schedule		19.08							Fee Schedule		18.52							Fee Schedule											319.41							Fee Schedule																				18.52							Fee Schedule																				
LIBRIUM 100 MG AMP	636	RC	J1990	CPT				Both			82.88	37.3	17.22	74.59		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	61.33							Fee Schedule																				18.52							Fee Schedule		74.59							Fee Schedule		21.3							Fee Schedule		17.22							Fee Schedule											21.3							Fee Schedule		17.22							Fee Schedule		
LIBRIUM:5 MG (CHLORDIAZEPOXIDE) CAP	250	RC	A9270	CPT				Both			1.58	0.71	0.01	1.42	0.01							Fee Schedule		1.17							Fee Schedule																													1.42							Fee Schedule																																															
LICE TREATMENT 1% (NIX)  59 ML	250	RC	A9270	CPT				Both			62.9	28.31	0.01	56.61	0.01							Fee Schedule		46.55							Fee Schedule																													56.61							Fee Schedule																																															
LICE TREATMENT LOTION 1%-59ML	250	RC	A9270	CPT				Both			26.25	11.81	0.01	23.63	0.01							Fee Schedule		19.43							Fee Schedule																													23.63							Fee Schedule																																															
LIDOCAINE 1% (10MG/ML) VIAL- 2ML	250	RC	A9270	CPT				Both			9.36	4.21	0.01	8.42	0.01							Fee Schedule		6.93							Fee Schedule																													8.42							Fee Schedule																																															
LIDOCAINE 1% (10MG/ML) VIAL- 2ML MPF	250	RC	A9270	CPT				Both			8.49	3.82	0.01	7.64	0.01							Fee Schedule		6.28							Fee Schedule																													7.64							Fee Schedule																																															
LIDOCAINE 1% (10MG/ML)-50ML SDV	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
LIDOCAINE 1% 10 MG/ML (PF) 5 ML VIAL	250	RC	A9270	CPT				Both			6.96	3.13	0.01	6.26	0.01							Fee Schedule		5.15							Fee Schedule																													6.26							Fee Schedule																																															
LIDOCAINE 1% 10MG/ML- 10ML MDV	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
LIDOCAINE 1% 10MG/ML- 20ML MDV	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
LIDOCAINE 1%-50ML MDV VIAL: PER ML	250	RC	A9270	CPT				Both			14.7	6.62	0.01	13.23	0.01							Fee Schedule		10.88							Fee Schedule																													13.23							Fee Schedule																																															
LIDOCAINE 100MG/SYRG	636	RC	J2001	CPT				Both			7.35	3.31	3.31	6.62		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	5.44							Fee Schedule																													6.62							Fee Schedule																																															
LIDOCAINE 2 GMS/500 ML PREMIX	636	RC	J2002	CPT				Both			20.22	9.1	9.1	18.2		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	14.96							Fee Schedule																													18.2							Fee Schedule																																															
LIDOCAINE 2% (100MG/5ML) SYRINGE	636	RC	J2003	CPT				Both			28.48	12.82	12.82	25.63		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	21.08							Fee Schedule																													25.63							Fee Schedule																																															
LIDOCAINE 2% (20MG/ML) VIAL- 2ML MPF	250	RC	A9270	CPT				Both			13.5	6.08	0.01	12.15	0.01							Fee Schedule		9.99							Fee Schedule																													12.15							Fee Schedule																																															
LIDOCAINE 2% 10 ML	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
LIDOCAINE 2% 20MG/ML-5 ML VIAL FOR DRIPS	250	RC	J2003	CPT				Both			13.5	6.08	6.08	12.15	8.78							Fee Schedule		9.99							Fee Schedule																													12.15							Fee Schedule																																															
LIDOCAINE 2% 50 ML MDV	250	RC	A9270	CPT				Both			15.08	6.79	0.01	13.57	0.01							Fee Schedule		11.16							Fee Schedule																													13.57							Fee Schedule																																															
LIDOCAINE 2% JELLY  UROJECT	250	RC	A9270	CPT				Both			27.3	12.29	0.01	24.57	0.01							Fee Schedule		20.2							Fee Schedule																													24.57							Fee Schedule																																															
LIDOCAINE 2% VISC- 100ML BOTTLE	250	RC	A9270	CPT				Both			39.6	17.82	0.01	35.64	0.01							Fee Schedule		29.3							Fee Schedule																													35.64							Fee Schedule																																															
LIDOCAINE 2% VISC- 15ML UD	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
LIDOCAINE 2%(20MG/ML)-20 ML VIAL	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
LIDOCAINE 2GMS/250ML PREMIX-PEDIATRIC	636	RC	J2003	CPT				Both			25.2	11.34	11.34	22.68		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	18.65							Fee Schedule																													22.68							Fee Schedule																																															
LIDOCAINE 300 MG/30 ML (PUDENDAL)	250	RC						Both			36.75	16.54	16.54	33.08	23.89							Fee Schedule		27.2							Fee Schedule																													33.08							Fee Schedule																																															
LIDOCAINE 4 PRE DRP	636	RC	J2001	CPT				Both			19.95	8.98	8.98	17.96		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	14.76							Fee Schedule																													17.96							Fee Schedule																																															
LIDOCAINE 4% TOP CREAM- 5GM SINGLE DOSE	250	RC	A9270	CPT				Both			14.4	6.48	0.01	12.96	0.01							Fee Schedule		10.66							Fee Schedule																													12.96							Fee Schedule																																															
LIDOCAINE 4% TOPICAL SOLN-120ML	250	RC	A9270	CPT				Both			20.6	9.27	0.01	18.54	0.01							Fee Schedule		15.24							Fee Schedule																													18.54							Fee Schedule																																															
LIDOCAINE 4% TOPICAL SOLUTION-50ML	250	RC	A9270	CPT				Both			144	64.8	0.01	129.6	0.01							Fee Schedule		106.56							Fee Schedule																													129.6							Fee Schedule																																															
LIDOCAINE 5% OINT	250	RC	A9270	CPT				Both			47.25	21.26	0.01	42.53	0.01							Fee Schedule		34.97							Fee Schedule																													42.53							Fee Schedule																																															
LIDOCAINE 5% OINT-30GM	250	RC	A9270	CPT				Both			9.45	4.25	0.01	8.51	0.01							Fee Schedule		6.99							Fee Schedule																													8.51							Fee Schedule																																															
LIDOCAINE 605 SERUM	301	RC	80176	CPT				Both			85.05	38.27	13.06	76.55	13.06							Fee Schedule		16.32							Fee Schedule		15.13							Fee Schedule		14.69							Fee Schedule											76.55							Fee Schedule																				14.69							Fee Schedule																				
LIDOCAINE AND PRILOCAIN 2.5% CREAM- 5 GM	250	RC	A9270	CPT				Both			25.2	11.34	0.01	22.68	0.01							Fee Schedule		18.65							Fee Schedule																				14.69							Fee Schedule		22.68							Fee Schedule		16.89							Fee Schedule		13.66							Fee Schedule											16.89							Fee Schedule		13.66							Fee Schedule		
"LIDOCAINE HCL 2% / EPI 1:50,000 ASTRAPAK"	250	RC						Both			11.55	5.2	5.2	10.4	7.51							Fee Schedule		8.55							Fee Schedule																													10.4							Fee Schedule																																															
LIDOCAINE HCL 4% TOPICAL SOL-5ML	636	RC	J3490	CPT				Both			14.49	6.52	6.52	13.04		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	10.72							Fee Schedule																													13.04							Fee Schedule																																															
LIDOCAINE PREMIX	270	RC						Both			9.45	4.25	4.25	8.51	6.14							Fee Schedule		6.99							Fee Schedule																													8.51							Fee Schedule																																															
LIDOCAINE SPRAY 10	250	RC						Both			122.85	55.28	55.28	110.57	79.85							Fee Schedule		90.91							Fee Schedule																													110.57							Fee Schedule																																															
LIDOCAINE W/EPI 1%-.001%-20ML MDV	250	RC	J2004	CPT				Both			6.3	2.84	2.84	5.67	4.1							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
LIDOCAINE W/EPI 1%-EPI 1:200000 30ML SDV	250	RC	J2004	CPT				Both			55.38	24.92	24.92	49.84	36							Fee Schedule		40.98							Fee Schedule																													49.84							Fee Schedule																																															
LIDOCAINE W/EPI 1.5%-1:200000-5ML AMP	250	RC	J2004	CPT				Both			6.3	2.84	2.84	5.67	4.1							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
LIDOCAINE W/EPI 2%-0.001%-50ML MDV	250	RC	J2004	CPT				Both			6.3	2.84	2.84	5.67	4.1							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
LIDODERM 5% TRANSDERMAL PATCH	250	RC	A9270	CPT				Both			29.4	13.23	0.01	26.46	0.01							Fee Schedule		21.76							Fee Schedule																													26.46							Fee Schedule																																															
LIFENET TENDON SHORT #04-1823-011 (HILLC	278	RC	C1762	CPT				Both			2471.7	1112.27	1112.27	2224.53		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1829.06							Fee Schedule																													2224.53							Fee Schedule																																															
LIGA CLIPS	270	RC						Both			18.9	8.51	8.51	17.01	12.29							Fee Schedule		13.99							Fee Schedule																													17.01							Fee Schedule																																															
LIGAMENT CLAMP	272	RC						Both			580.65	261.29	261.29	522.59	377.42							Fee Schedule		429.68							Fee Schedule																													522.59							Fee Schedule																																															
LIGAMENT PATELLAR # 447-13803S ( STRYKER	278	RC	C1762	CPT				Both			5654.25	2544.41	2544.41	5088.83		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	4184.15							Fee Schedule																													5088.83							Fee Schedule																																															
LIGAMENT PATELLAR HEMI ( DCI )	278	RC	C1762	CPT				Both			4646.25	2090.81	2090.81	4181.63		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	3438.23							Fee Schedule																													4181.63							Fee Schedule																																															
LIGASURE 10MM LS1037  ( SENECA )	272	RC						Both			1238	557.1	557.1	1114.2	804.7							Fee Schedule		916.12							Fee Schedule																													1114.2							Fee Schedule																																															
LIGASURE 5 CLIPS # LS1500  (DISC.)	272	RC						Both			1909.95	859.48	859.48	1718.96	1241.47							Fee Schedule		1413.36							Fee Schedule																													1718.96							Fee Schedule																																															
LIGASURE LF4318 *DISC.*	272	RC						Both			1886.85	849.08	849.08	1698.17	1226.45							Fee Schedule		1396.27							Fee Schedule																													1698.17							Fee Schedule																																															
LIGASURE LF4418  SUSTAINABILITY	272	RC						Both			1782	801.9	801.9	1603.8	1158.3							Fee Schedule		1318.68							Fee Schedule																													1603.8							Fee Schedule																																															
LIGASURE RETRACTABLE L-HOOK 37CM LF5637	272	RC						Both			1954	879.3	879.3	1758.6	1270.1							Fee Schedule		1445.96							Fee Schedule																													1758.6							Fee Schedule																																															
LIGASURE STAPLER 20CM # LS1020	272	RC						Both			1129.8	508.41	508.41	1016.82	734.37							Fee Schedule		836.05							Fee Schedule																													1016.82							Fee Schedule																																															
LIGASURE STAPLER LF1937 MEDLINE	272	RC						Both			971	436.95	436.95	873.9	631.15							Fee Schedule		718.54							Fee Schedule																													873.9							Fee Schedule																																															
LIGASURE STAPLER LS1037	272	RC						Both			1129.8	508.41	508.41	1016.82	734.37							Fee Schedule		836.05							Fee Schedule																													1016.82							Fee Schedule																																															
LIGHT HANDLE COVERS DEROYAL #26-012	272	RC						Both			5	2.25	2.25	4.5	3.25							Fee Schedule		3.7							Fee Schedule																													4.5							Fee Schedule																																															
MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITH CC					436	DRG		Inpatient			24224.65	10901.09	10901.09	10901.09							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period	
LIMBITROL 5-12.5 MG TABLET UD	250	RC	A9270	CPT				Both			5.25	2.36	0.01	4.73	0.01							Fee Schedule		3.89							Fee Schedule																													4.73							Fee Schedule																																															
LINDANE 1% LOTION-60ML	250	RC	A9270	CPT				Both			431.11	194	0.01	388	0.01							Fee Schedule		319.02							Fee Schedule																													388							Fee Schedule																																															
LINDANE 1% SHAMPOO-60ML	250	RC	A9270	CPT				Both			338.28	152.23	0.01	304.45	0.01							Fee Schedule		250.33							Fee Schedule																													304.45							Fee Schedule																																															
LINEAR CUTTER TCT75	272	RC						Both			930.3	418.64	418.64	837.27	604.7							Fee Schedule		688.42							Fee Schedule																													837.27							Fee Schedule																																															
LINEZOLID 600MG TABLET	250	RC	A9270	CPT				Both			1009.05	454.07	0.01	908.15	0.01							Fee Schedule		746.7							Fee Schedule																													908.15							Fee Schedule																																															
LINEZOLID 600MG/300ML PREMIX	636	RC	J2020	CPT				Both			226.8	102.06	2.34	204.12		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	167.83							Fee Schedule		2.34							Fee Schedule																				204.12							Fee Schedule																																															
LINVATEC CUFF REPAIR SUTURE RETREIVER	272	RC						Both			118.65	53.39	2.11	106.79	77.12							Fee Schedule		87.8							Fee Schedule																				2.27							Fee Schedule		106.79							Fee Schedule		2.61							Fee Schedule		2.11							Fee Schedule											2.61							Fee Schedule		2.11							Fee Schedule		
LINZESS 145 MCG (LINACLOTIDE) CAPS	250	RC	A9270	CPT				Both			33.9	15.26	0.01	30.51	0.01							Fee Schedule		25.09							Fee Schedule																													30.51							Fee Schedule																																															
LIPASE	301	RC	83690	CPT				Both			42	18.9	6.13	37.8	6.13							Fee Schedule		7.65							Fee Schedule		7.1							Fee Schedule		6.89							Fee Schedule											37.8							Fee Schedule																				6.89							Fee Schedule																				
LIPASE 17601 PLEURAL FLUID	301	RC	83690	CPT				Both			42	18.9	6.13	37.8	6.13							Fee Schedule		7.65							Fee Schedule		7.1							Fee Schedule		6.89							Fee Schedule		6.89							Fee Schedule		37.8							Fee Schedule		7.92							Fee Schedule		6.41							Fee Schedule		6.89							Fee Schedule		7.92							Fee Schedule		6.41							Fee Schedule		
LIPID PANEL	301	RC	80061	CPT				Both			124.95	56.23	6.41	112.46	11.9							Fee Schedule		14.88							Fee Schedule		13.79							Fee Schedule		13.39							Fee Schedule		6.89							Fee Schedule		112.46							Fee Schedule		7.92							Fee Schedule		6.41							Fee Schedule		13.39							Fee Schedule		7.92							Fee Schedule		6.41							Fee Schedule		
LIPO.INNER LINER FOR CANIST.#20-5154-00	271	RC						Both			26.25	11.81	11.81	23.63	17.06							Fee Schedule		19.43							Fee Schedule																				13.39							Fee Schedule		23.63							Fee Schedule		15.4							Fee Schedule		12.45							Fee Schedule											15.4							Fee Schedule		12.45							Fee Schedule		
LIPOGEMS PROCEDURAL KIT	272	RC						Both			4709.25	2119.16	2119.16	4238.33	3061.01							Fee Schedule		3484.85							Fee Schedule																													4238.33							Fee Schedule																																															
LIPOPROTEIN A 34604 SERUM 1ML	301	RC	83695	CPT				Both			190.05	85.52	11.51	171.05	11.51							Fee Schedule		14.39							Fee Schedule		14.75							Fee Schedule		14.32							Fee Schedule											171.05							Fee Schedule																				14.32							Fee Schedule																				
LIPOPROTEIN LOW DENSITY 8293	301	RC	83721	CPT				Both			52.5	23.63	8.48	47.25	8.48							Fee Schedule		10.6							Fee Schedule		10.82							Fee Schedule		10.5							Fee Schedule		14.32							Fee Schedule		47.25							Fee Schedule		16.47							Fee Schedule		13.32							Fee Schedule		10.5							Fee Schedule		16.47							Fee Schedule		13.32							Fee Schedule		
LIPOSUCT. 9 FT. TUBING #24-5103-00	272	RC						Both			24.15	10.87	9.77	21.74	15.7							Fee Schedule		17.87							Fee Schedule																				10.5							Fee Schedule		21.74							Fee Schedule		12.08							Fee Schedule		9.77							Fee Schedule											12.08							Fee Schedule		9.77							Fee Schedule		
LIPOSUCT.10 FT. TUBING #24-5102-02	272	RC						Both			25.2	11.34	11.34	22.68	16.38							Fee Schedule		18.65							Fee Schedule																													22.68							Fee Schedule																																															
LISINOPRIL  2.5MG (ZESTRIL) TABLET	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
LISINOPRIL  5MG (ZESTRIL) TABLET	250	RC	A9270	CPT				Both			6	2.7	0.01	5.4	0.01							Fee Schedule		4.44							Fee Schedule																													5.4							Fee Schedule																																															
LISINOPRIL 10MG (ZESTRIL) TABLET	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
LISINOPRIL 20MG (ZESTRIL) TABLET	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
LISTERIA  AB SERUM CF 34329	302	RC	86609	CPT				Both			73.5	33.08	11.45	66.15	11.45							Fee Schedule		14.31							Fee Schedule		13.27							Fee Schedule		12.88							Fee Schedule											66.15							Fee Schedule																				12.88							Fee Schedule																				
LISTERIA AB CSF 1ML REF 11012	302	RC	86609	CPT				Both			105	47.25	11.45	94.5	11.45							Fee Schedule		14.31							Fee Schedule		13.27							Fee Schedule		12.88							Fee Schedule		12.88							Fee Schedule		94.5							Fee Schedule		14.81							Fee Schedule		11.98							Fee Schedule		12.88							Fee Schedule		14.81							Fee Schedule		11.98							Fee Schedule		
LITE FOAM DRESSING 509393	272	RC						Both			6.3	2.84	2.84	14.81	4.1							Fee Schedule		4.66							Fee Schedule																				12.88							Fee Schedule		5.67							Fee Schedule		14.81							Fee Schedule		11.98							Fee Schedule											14.81							Fee Schedule		11.98							Fee Schedule		
LITHIUM CARBONATE 300 MG CAPSULE UD	250	RC	A9270	CPT				Both			5.25	2.36	0.01	4.73	0.01							Fee Schedule		3.89							Fee Schedule																													4.73							Fee Schedule																																															
LITHIUM CARBONATE ORAL CAPSULE 150MG	636	RC	A9270	CPT				Both			6	2.7	2.7	5.4		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	4.44							Fee Schedule																													5.4							Fee Schedule																																															
LITHIUM SERUM	301	RC	80178	CPT				Both			43.05	19.37	5.88	38.75	5.88							Fee Schedule		7.35							Fee Schedule		6.81							Fee Schedule		6.61							Fee Schedule											38.75							Fee Schedule																				6.61							Fee Schedule																				
LITHOTRIPTOR LITHOCRUSH V  BML-V232QR-26	272	RC						Both			1219	548.55	6.15	1097.1	792.35							Fee Schedule		902.06							Fee Schedule																				6.61							Fee Schedule		1097.1							Fee Schedule		7.6							Fee Schedule		6.15							Fee Schedule											7.6							Fee Schedule		6.15							Fee Schedule		
LITHOTRIPTOR V  BML-V232QR-30	272	RC						Both			994.35	447.46	447.46	894.92	646.33							Fee Schedule		735.82							Fee Schedule																													894.92							Fee Schedule																																															
LITTLE NOSES 1/8% DECONGEST DROPS- 15ML	250	RC	A9270	CPT				Both			11.59	5.22	0.01	10.43	0.01							Fee Schedule		8.58							Fee Schedule																													10.43							Fee Schedule																																															
LIVER CYTOSOL  AUTO AB 10527 1ML SER REF	302	RC	86376	CPT				Both			210	94.5	12.93	189	12.93							Fee Schedule		16.17							Fee Schedule		14.99							Fee Schedule		14.55							Fee Schedule											189							Fee Schedule																				14.55							Fee Schedule																				
"LIVER FIBROSIS, FIBROTEST 92688"	301	RC	81596	CPT				Both			606	272.7	13.53	545.4	46.76							Fee Schedule		72.19							Fee Schedule		74.36							Fee Schedule		72.19							Fee Schedule		14.55							Fee Schedule		545.4							Fee Schedule		16.73							Fee Schedule		13.53							Fee Schedule		72.19							Fee Schedule		16.73							Fee Schedule		13.53							Fee Schedule		
LIVOSTIN 0.05% OPTHL SOLN-5ML	250	RC	A9270	CPT				Both			179.55	80.8	0.01	161.6	0.01							Fee Schedule		132.87							Fee Schedule																				72.19							Fee Schedule		161.6							Fee Schedule		83.02							Fee Schedule		67.14							Fee Schedule											83.02							Fee Schedule		67.14							Fee Schedule		
LMA MASK SIZE 3 #LM-321-300  (SHARN)	272	RC						Both			34.65	15.59	15.59	31.19	22.52							Fee Schedule		25.64							Fee Schedule																													31.19							Fee Schedule																																															
LMA MASK SIZE 4 #LM-321-400  (SHARN)	272	RC						Both			38	17.1	17.1	34.2	24.7							Fee Schedule		28.12							Fee Schedule																													34.2							Fee Schedule																																															
LMA MASK SIZE 5 #LM-321-500  (SHARN)	272	RC						Both			33	14.85	14.85	29.7	21.45							Fee Schedule		24.42							Fee Schedule																													29.7							Fee Schedule																																															
LMA SIZE 1.0 DISP. ENTUB. LMI-329-100	270	RC						Both			42	18.9	18.9	37.8	27.3							Fee Schedule		31.08							Fee Schedule																													37.8							Fee Schedule																																															
LMA SIZE 1.5 DISP. ENTUB.  LMI-329-150	270	RC						Both			38	17.1	17.1	34.2	24.7							Fee Schedule		28.12							Fee Schedule																													34.2							Fee Schedule																																															
LMA SIZE 2.0 DISP. ENTUB.  LMI-329-200	270	RC						Both			38	17.1	17.1	34.2	24.7							Fee Schedule		28.12							Fee Schedule																													34.2							Fee Schedule																																															
LMA SIZE 2.5 DISP. ENTUB.  LMI-329-250	270	RC						Both			42	18.9	18.9	37.8	27.3							Fee Schedule		31.08							Fee Schedule																													37.8							Fee Schedule																																															
LMA SIZE 3.0 DISP. ENTUB.  LMI-329-300	270	RC						Both			38	17.1	17.1	34.2	24.7							Fee Schedule		28.12							Fee Schedule																													34.2							Fee Schedule																																															
LOAD CARDS # 802510  STERIS	270	RC						Both			11.55	5.2	5.2	10.4	7.51							Fee Schedule		8.55							Fee Schedule																													10.4							Fee Schedule																																															
LOCAL	370	RC						Both			85.05	38.27	38.27	76.55	55.28							Fee Schedule		62.94							Fee Schedule																													76.55							Fee Schedule																																															
LOCAL XYLOCAINE	250	RC						Both			3.15	1.42	1.42	2.84	2.05							Fee Schedule		2.33							Fee Schedule																													2.84							Fee Schedule																																															
LOKELMA 10GM ORAL SUSP/1PACKET	636	RC						Both			103.38	46.52	46.52	93.04		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	76.5							Fee Schedule																													93.04							Fee Schedule																																															
LONE STAR DISP. RETRACTOR RING #3304G	272	RC						Both			311	139.95	139.95	279.9	202.15							Fee Schedule		230.14							Fee Schedule																													279.9							Fee Schedule																																															
LONE STAR ELASTIC STAYS #3350L-4G	272	RC						Both			63	28.35	28.35	56.7	40.95							Fee Schedule		46.62							Fee Schedule																													56.7							Fee Schedule																																															
LONG FORAMEN NEEDLE #9001-L	272	RC						Both			1380	621	621	1242	897							Fee Schedule		1021.2							Fee Schedule																													1242							Fee Schedule																																															
LONG LEG SPLINT BILAT.  2  ORTHO GLASS	274	RC	A4590	CPT				Both			756	340.2	24.09	680.4		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	559.44							Fee Schedule											24.09							Fee Schedule											680.4							Fee Schedule																																															
LONG LEG SPLINT BILAT.  3  ORTHO GLASS	274	RC	A4590	CPT				Both			1008	453.6	24.09	907.2		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	745.92							Fee Schedule											24.09							Fee Schedule											907.2							Fee Schedule																																															
LONG LEG SPLINT BILAT.  4  ORTHO GLASS	274	RC	A4590	CPT				Both			1260	567	24.09	1134		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	932.4							Fee Schedule											24.09							Fee Schedule											1134							Fee Schedule																																															
LONG LEG SPLINT BILAT.  5  ORTHO GLASS	274	RC	A4590	CPT				Both			1512	680.4	24.09	1360.8		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1118.88							Fee Schedule											24.09							Fee Schedule											1360.8							Fee Schedule																																															
LONG LEG SPLINT R & L  2  ORTHO GLASS	270	RC						Both			378	170.1	170.1	340.2	245.7							Fee Schedule		279.72							Fee Schedule																													340.2							Fee Schedule																																															
LONG LEG SPLINT R & L  3  ORTHO GLASS	274	RC						Both			504	226.8	226.8	453.6		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	372.96							Fee Schedule																													453.6							Fee Schedule																																															
LONG LEG SPLINT R & L  4  ORTHO GLASS	274	RC						Both			630	283.5	283.5	567		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	466.2							Fee Schedule																													567							Fee Schedule																																															
LONG LEG SPLINT R & L  5  ORTHO GLASS	270	RC						Both			756	340.2	340.2	680.4	491.4							Fee Schedule		559.44							Fee Schedule																													680.4							Fee Schedule																																															
LOOP OSTOMY ROD #22355 (SENECA)	272	RC						Both			8.4	3.78	3.78	7.56	5.46							Fee Schedule		6.22							Fee Schedule																													7.56							Fee Schedule																																															
LOOPS VESSEL STERILE (SENECA)	272	RC						Both			4.2	1.89	1.89	3.78	2.73							Fee Schedule		3.11							Fee Schedule																													3.78							Fee Schedule																																															
LOPERAMIDE 1 MG/  5ML ORAL LIQUID 4 OZ	250	RC	A9270	CPT				Both			17.64	7.94	0.01	15.88	0.01							Fee Schedule		13.05							Fee Schedule																													15.88							Fee Schedule																																															
LOPERAMIDE 1 MG/7.5ML ORAL LIQUID UD	250	RC	A9270	CPT				Both			17.64	7.94	0.01	15.88	0.01							Fee Schedule		13.05							Fee Schedule																													15.88							Fee Schedule																																															
LOPERAMIDE 2MG (IMODIUM) CAPSULE	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
LORABID 200 MG CAPSULE UD	250	RC	A9270	CPT				Both			10.5	4.73	0.01	9.45	0.01							Fee Schedule		7.77							Fee Schedule																													9.45							Fee Schedule																																															
LORABID 200MG/5ML SUSP-50ML	250	RC	A9270	CPT				Both			78.75	35.44	0.01	70.88	0.01							Fee Schedule		58.28							Fee Schedule																													70.88							Fee Schedule																																															
LORazepam 0.5MG (ATIVAN) TABLET	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
LORazepam 1MG (ATIVAN) TABLET	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
LORazepam 20MG/ 10ML (ATIVAN) INJECTION	636	RC	J2060	CPT				Both			36	16.2	2.37	32.4		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	26.64							Fee Schedule		2.37							Fee Schedule		14.01							Fee Schedule											32.4							Fee Schedule																																															
LORazepam 2MG/ML (ATIVAN) INJECTION	636	RC	J2060	CPT				Both			12.6	5.67	2.14	14.01		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	9.32							Fee Schedule		2.37							Fee Schedule		14.01							Fee Schedule		2.3							Fee Schedule		11.34							Fee Schedule		2.65							Fee Schedule		2.14							Fee Schedule											2.65							Fee Schedule		2.14							Fee Schedule		
LORazepam 2MG/ML (ATIVAN) SYRINGE	636	RC	J2060	CPT				Both			12.93	5.82	2.14	14.01		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	9.57							Fee Schedule		2.37							Fee Schedule		14.01							Fee Schedule		2.3							Fee Schedule		11.64							Fee Schedule		2.65							Fee Schedule		2.14							Fee Schedule											2.65							Fee Schedule		2.14							Fee Schedule		
LORAZEPAM DRIP	636	RC	J2060	CPT				Both			51.45	23.15	2.14	46.31		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	38.07							Fee Schedule		2.37							Fee Schedule		14.01							Fee Schedule		2.3							Fee Schedule		46.31							Fee Schedule		2.65							Fee Schedule		2.14							Fee Schedule											2.65							Fee Schedule		2.14							Fee Schedule		
LORCET 10/650 TABS	250	RC	A9270	CPT				Both			1.79	0.81	0.01	2.65	0.01							Fee Schedule		1.32							Fee Schedule																				2.3							Fee Schedule		1.61							Fee Schedule		2.65							Fee Schedule		2.14							Fee Schedule											2.65							Fee Schedule		2.14							Fee Schedule		
LORTAB 10 MG TABLET UD	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
LORTAB LIQUID 2.5 MG/5 ML :CHG BY 5ML	250	RC	A9270	CPT				Both			5.51	2.48	0.01	4.96	0.01							Fee Schedule		4.08							Fee Schedule																													4.96							Fee Schedule																																															
LOSARTAN  25 MG (COZAAR) TAB	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
LOSARTAN  50 MG (COZAAR) TAB	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
LOSARTAN 100 MG (COZAAR) TAB	250	RC	A9270	CPT				Both			9.45	4.25	0.01	8.51	0.01							Fee Schedule		6.99							Fee Schedule																													8.51							Fee Schedule																																															
LOTEMAX 0.5% OPTH.SOL.	250	RC	A9270	CPT				Both			230.33	103.65	0.01	207.3	0.01							Fee Schedule		170.44							Fee Schedule																													207.3							Fee Schedule																																															
LOTRIMIN 1% SOL.(CHG.BY ML.DR DAVIS)	250	RC	A9270	CPT				Both			4.2	1.89	0.01	3.78	0.01							Fee Schedule		3.11							Fee Schedule																													3.78							Fee Schedule																																															
LOTRIMIN 1% SOL.30 ML	250	RC	A9270	CPT				Both			103.95	46.78	0.01	93.56	0.01							Fee Schedule		76.92							Fee Schedule																													93.56							Fee Schedule																																															
LOTRIMIN SOLUTION	250	RC	A9270	CPT				Both			27.37	12.32	0.01	24.63	0.01							Fee Schedule		20.25							Fee Schedule																													24.63							Fee Schedule																																															
LOTRISONE CREAM 45 GMS	250	RC						Both			180.6	81.27	81.27	162.54	117.39							Fee Schedule		133.64							Fee Schedule																													162.54							Fee Schedule																																															
LOTRISONE LOTION 30 ML	250	RC	A9270	CPT				Both			180.6	81.27	0.01	162.54	0.01							Fee Schedule		133.64							Fee Schedule																													162.54							Fee Schedule																																															
LOTRONEX (ALOSETRON) TAB 0.5MG	250	RC	A9270	CPT				Both			52	23.4	0.01	46.8	0.01							Fee Schedule		38.48							Fee Schedule																													46.8							Fee Schedule																																															
LOVASTATIN 10MG (MEVACOR) TABLET	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
LOVASTATIN 20MG (MEVACOR) TABLET	250	RC	A9270	CPT				Both			8.4	3.78	0.01	7.56	0.01							Fee Schedule		6.22							Fee Schedule																													7.56							Fee Schedule																																															
LOVENOX  30 MG/0.3ML (ENOXAPARIN)  PFS	636	RC	J1650	CPT				Both			94.5	42.53	0.55	85.05		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	69.93							Fee Schedule		0.55							Fee Schedule		21.6							Fee Schedule											85.05							Fee Schedule																																															
LOVENOX  40 MG/0.4ML (ENOXAPARIN)  PFS	636	RC	J1650	CPT				Both			124.95	56.23	0.5	112.46		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	92.46							Fee Schedule		0.55							Fee Schedule		21.6							Fee Schedule		0.54							Fee Schedule		112.46							Fee Schedule		0.62							Fee Schedule		0.5							Fee Schedule											0.62							Fee Schedule		0.5							Fee Schedule		
LOVENOX  60 MG/0.6ML (ENOXAPARIN) PFS	636	RC	J1650	CPT				Both			191.1	86	0.5	171.99		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	141.41							Fee Schedule		0.55							Fee Schedule		21.6							Fee Schedule		0.54							Fee Schedule		171.99							Fee Schedule		0.62							Fee Schedule		0.5							Fee Schedule											0.62							Fee Schedule		0.5							Fee Schedule		
LOVENOX  80 MG/0.8ML (ENOXAPARIN) PFS	636	RC	J1650	CPT				Both			254.1	114.35	0.5	228.69		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	188.03							Fee Schedule		0.55							Fee Schedule		21.6							Fee Schedule		0.54							Fee Schedule		228.69							Fee Schedule		0.62							Fee Schedule		0.5							Fee Schedule											0.62							Fee Schedule		0.5							Fee Schedule		
LOVENOX 100 MG/ML (ENOXAPARIN)  PFS	636	RC	J1650	CPT				Both			315	141.75	0.5	283.5		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	233.1							Fee Schedule		0.55							Fee Schedule		21.6							Fee Schedule		0.54							Fee Schedule		283.5							Fee Schedule		0.62							Fee Schedule		0.5							Fee Schedule											0.62							Fee Schedule		0.5							Fee Schedule		
LOVENOX 120 MG/0.8ML (ENOXAPARIN) PFS	636	RC	J1650	CPT				Both			347.55	156.4	0.5	312.8		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	257.19							Fee Schedule		0.55							Fee Schedule		21.6							Fee Schedule		0.54							Fee Schedule		312.8							Fee Schedule		0.62							Fee Schedule		0.5							Fee Schedule											0.62							Fee Schedule		0.5							Fee Schedule		
LOVENOX 150 MG/ML (ENOXAPARIN)  PFS	636	RC	J1650	CPT				Both			477.75	214.99	0.5	429.98		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	353.54							Fee Schedule		0.55							Fee Schedule		21.6							Fee Schedule		0.54							Fee Schedule		429.98							Fee Schedule		0.62							Fee Schedule		0.5							Fee Schedule											0.62							Fee Schedule		0.5							Fee Schedule		
LOVENOX 1MG/ KG -PHARMACY TO DOSE	636	RC	J1650	CPT				Both			279.3	125.69	0.5	251.37		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	206.68							Fee Schedule		0.55							Fee Schedule		21.6							Fee Schedule		0.54							Fee Schedule		251.37							Fee Schedule		0.62							Fee Schedule		0.5							Fee Schedule											0.62							Fee Schedule		0.5							Fee Schedule		
LOW PROFILE RESERVOIR 100ML #720185-01	272	RC						Both			11370	5116.5	0.5	10233	7390.5							Fee Schedule		8413.8							Fee Schedule																				0.54							Fee Schedule		10233							Fee Schedule		0.62							Fee Schedule		0.5							Fee Schedule											0.62							Fee Schedule		0.5							Fee Schedule		
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH MCC					438	DRG		Inpatient			59066.86	26580.09	26580.09	26580.09							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period				5841.24	5841.24	5841.24	1 through 10									0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period	
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH CC					439	DRG		Inpatient			31044.24	13969.91	13969.91	13969.91							0		No services performed during 15 month lookback period. 				1937.67	1937.67	1937.67	1 through 10									0		No services performed during 15 month lookback period				3373.72	3373.72	3373.72	1 through 10						5180.51	5180.51	5180.51	1 through 10									0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period	
LOXIPINE 50 MG CAPSULE UD	250	RC	A9270	CPT				Both			5.82	2.62	0.01	5.24	0.01							Fee Schedule		4.31							Fee Schedule																													5.24							Fee Schedule																																															
LPT TO BERYLLIUM 17573 GREEN TOP 30 ML	300	RC	86353	CPT				Both			420	189	43.58	378	43.58							Fee Schedule		54.47							Fee Schedule		50.5							Fee Schedule		49.03							Fee Schedule											378							Fee Schedule																				49.03							Fee Schedule																				
LR IRRIG. 5000ML  2B7489	272	RC						Both			28.35	12.76	12.76	56.38	18.43							Fee Schedule		20.98							Fee Schedule																				49.03							Fee Schedule		25.52							Fee Schedule		56.38							Fee Schedule		45.6							Fee Schedule											56.38							Fee Schedule		45.6							Fee Schedule		
LRP4  AUTOANTIBODY TEST 94744	302	RC	86255	CPT				Both			2160	972	10.71	1944	10.71							Fee Schedule		13.39							Fee Schedule		12.41							Fee Schedule		12.05							Fee Schedule											1944							Fee Schedule																				12.05							Fee Schedule																				
LSI SOLUTIONS TK QUICK LOAD UNIT 030510	272	RC						Both			135	60.75	11.21	121.5	87.75							Fee Schedule		99.9							Fee Schedule																				12.05							Fee Schedule		121.5							Fee Schedule		13.86							Fee Schedule		11.21							Fee Schedule											13.86							Fee Schedule		11.21							Fee Schedule		
LSI SOLUTIONS TK TI-KNOT DEVICE 030404	272	RC						Both			597	268.65	268.65	537.3	388.05							Fee Schedule		441.78							Fee Schedule																													537.3							Fee Schedule																																															
LTA KIT	270	RC						Both			57.75	25.99	25.99	51.98	37.54							Fee Schedule		42.74							Fee Schedule																													51.98							Fee Schedule																																															
LTD EXT VENOUS	921	RC	93971	CPT				Both			791.7	356.27	108.35	800	507							Per Diem		585.86							Fee Schedule											108.35							Fee Schedule											712.53							Fee Schedule																				800							Per Diem																				
LUBRICANT EYE DROPS-15ML	250	RC	A9270	CPT				Both			17.85	8.03	0.01	16.07	0.01							Fee Schedule		13.21							Fee Schedule																													16.07							Fee Schedule																																															
LUBRICANT EYE OINTMENT-3.5GM	250	RC	A9270	CPT				Both			24.15	10.87	0.01	21.74	0.01							Fee Schedule		17.87							Fee Schedule																													21.74							Fee Schedule																																															
LUBRICATING DEODORANT 78501	270	RC	A4394	CPT				Both			1	0.45	0.45	3.8	2.33							Fee Schedule		0.74							Fee Schedule		3.8							Fee Schedule																				0.9							Fee Schedule																																															
LUBRIDERM LOTION	250	RC	A9270	CPT				Both			10.36	4.66	0.01	9.32	0.01							Fee Schedule		7.67							Fee Schedule																				3.69							Fee Schedule		9.32							Fee Schedule		4.24							Fee Schedule		3.43							Fee Schedule											4.24							Fee Schedule		3.43							Fee Schedule		
LUBRI-SIL 2-WAY FOLEY 12FR (BD MED)	272	RC						Both			11	4.95	4.95	9.9	7.15							Fee Schedule		8.14							Fee Schedule																													9.9							Fee Schedule																																															
LUBRI-SIL 3-WAY 30ML FOLEY 22FR 73022L	272	RC						Both			31	13.95	13.95	27.9	20.15							Fee Schedule		22.94							Fee Schedule																													27.9							Fee Schedule																																															
LUBRI-SIL COUNCIL TIP FOLEY 16F (BD MED)	272	RC						Both			56	25.2	25.2	50.4	36.4							Fee Schedule		41.44							Fee Schedule																													50.4							Fee Schedule																																															
LUBRI-SIL COUNCIL TIP FOLEY 20F (BD MED)	272	RC						Both			56	25.2	25.2	50.4	36.4							Fee Schedule		41.44							Fee Schedule																													50.4							Fee Schedule																																															
LUBRISKIN  (LUBRIDERM) LOTION	250	RC	A9270	CPT				Both			10.5	4.73	0.01	9.45	0.01							Fee Schedule		7.77							Fee Schedule																													9.45							Fee Schedule																																															
LUFYLLIN GG LIQ OZ	250	RC	A9270	CPT				Both			1.66	0.75	0.01	1.49	0.01							Fee Schedule		1.23							Fee Schedule																													1.49							Fee Schedule																																															
LUMBAR  6V WITH BENDING	320	RC	72114	CPT				Both			315	141.75	33.33	318	36.85							Fee Schedule		37.86							Fee Schedule											33.33							Fee Schedule											283.5							Fee Schedule																				318							Per Diem																				
LUMBAR 3V	320	RC	72100	CPT				Both			315	141.75	19.13	318	19.38							Fee Schedule		22.92							Fee Schedule											19.13							Fee Schedule											283.5							Fee Schedule																				318							Per Diem																				
LUMBAR 5V	320	RC	72110	CPT				Both			315	141.75	25.87	318	26.95							Fee Schedule		32.01							Fee Schedule											25.87							Fee Schedule											283.5							Fee Schedule																				318							Per Diem																				
LUMBAR INJECTION	370	RC	62322	CPT				Both			250	112.5	112.25	225	112.25							Fee Schedule		185							Fee Schedule																													225							Fee Schedule																																															
LUMBAR MYELOGRAM	320	RC	72265	CPT				Both			689.85	310.43	41.51	620.87	41.51							Fee Schedule		51.49							Fee Schedule											115.16							Fee Schedule											620.87							Fee Schedule																				318							Per Diem																				
LUMBAR OR SACRAL SINGLE LEVEL EPD INJ	370	RC	64483	CPT				Both			278.25	125.21	125.21	250.43	145.04							Fee Schedule		205.91							Fee Schedule																													250.43							Fee Schedule																																															
LUMBAR PUNCT SAFETY PEDIATRIC 26-LP2SFA	272	RC						Both			72	32.4	32.4	64.8	46.8							Fee Schedule		53.28							Fee Schedule																													64.8							Fee Schedule																																															
LUMBAR PUNCT TRAY SAFETY ADULT #648	272	RC						Both			61	27.45	27.45	54.9	39.65							Fee Schedule		45.14							Fee Schedule																													54.9							Fee Schedule																																															
LUMBAR PUNCT. TRY. SAFETY INFANT ( CARDI	272	RC						Both			58.8	26.46	26.46	52.92	38.22							Fee Schedule		43.51							Fee Schedule																													52.92							Fee Schedule																																															
LUMBAR RIB BELT LARGE	270	RC						Both			19.69	8.86	8.86	17.72	12.8							Fee Schedule		14.57							Fee Schedule																													17.72							Fee Schedule																																															
LUMBAR RIB BELT MEDIUM	270	RC						Both			19.69	8.86	8.86	17.72	12.8							Fee Schedule		14.57							Fee Schedule																													17.72							Fee Schedule																																															
LUMBAR RIB BELT SMALL	270	RC						Both			19.69	8.86	8.86	17.72	12.8							Fee Schedule		14.57							Fee Schedule																													17.72							Fee Schedule																																															
LUMBAR RIB BELT X LARGE	270	RC						Both			19.69	8.86	8.86	17.72	12.8							Fee Schedule		14.57							Fee Schedule																													17.72							Fee Schedule																																															
LUMBAR ROLL	271	RC						Both			18.74	8.43	8.43	16.87	12.18							Fee Schedule		13.87							Fee Schedule																													16.87							Fee Schedule																																															
LUMBAR SACRAL SUPPORT UNIV 3717-00	274	RC	L0625	CPT				Both			137.55	61.9	44.08	123.8		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	101.79							Fee Schedule		44.08							Fee Schedule																				123.8							Fee Schedule																																															
LUMBAR SACRAL SUPPORT UNIV. 13850000	274	RC	L0625	CPT				Both			73	32.85	32.85	65.7		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	54.02							Fee Schedule		44.08							Fee Schedule											42.8							Fee Schedule		65.7							Fee Schedule		49.22							Fee Schedule		39.8							Fee Schedule											49.22							Fee Schedule		39.8							Fee Schedule		
LUMBAR SUPPORT LARGE	274	RC	L0450	CPT				Both			53.71	24.17	24.17	149.45		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	39.75							Fee Schedule		149.45							Fee Schedule											42.8							Fee Schedule		48.34							Fee Schedule		49.22							Fee Schedule		39.8							Fee Schedule											49.22							Fee Schedule		39.8							Fee Schedule		
LUMBAR SUPPORT MEDIUM	274	RC	L0450	CPT				Both			53.71	24.17	24.17	166.87		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	39.75							Fee Schedule		149.45							Fee Schedule											145.1							Fee Schedule		48.34							Fee Schedule		166.87							Fee Schedule		134.94							Fee Schedule											166.87							Fee Schedule		134.94							Fee Schedule		
LUMBAR SUPPORT SMALL	274	RC	L0450	CPT				Both			53.71	24.17	24.17	166.87		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	39.75							Fee Schedule		149.45							Fee Schedule											145.1							Fee Schedule		48.34							Fee Schedule		166.87							Fee Schedule		134.94							Fee Schedule											166.87							Fee Schedule		134.94							Fee Schedule		
LUMBAR SUPPORT UNIVERSAL	274	RC	L0450	CPT				Both			53.71	24.17	24.17	166.87		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	39.75							Fee Schedule		149.45							Fee Schedule											145.1							Fee Schedule		48.34							Fee Schedule		166.87							Fee Schedule		134.94							Fee Schedule											166.87							Fee Schedule		134.94							Fee Schedule		
LUMBAR SUPPORT W SUSPENDERS INDUSTRIAL	274	RC	L0450	CPT				Both			69.14	31.11	31.11	166.87		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	51.16							Fee Schedule		149.45							Fee Schedule											145.1							Fee Schedule		62.23							Fee Schedule		166.87							Fee Schedule		134.94							Fee Schedule											166.87							Fee Schedule		134.94							Fee Schedule		
LUMBAR SUPPORT X LARGE	274	RC	L0450	CPT				Both			46.78	21.05	21.05	166.87		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	34.62							Fee Schedule		149.45							Fee Schedule											145.1							Fee Schedule		42.1							Fee Schedule		166.87							Fee Schedule		134.94							Fee Schedule											166.87							Fee Schedule		134.94							Fee Schedule		
LUMBAR SUPPORT XX LARGE	274	RC	L0450	CPT				Both			53.71	24.17	24.17	166.87		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	39.75							Fee Schedule		149.45							Fee Schedule											145.1							Fee Schedule		48.34							Fee Schedule		166.87							Fee Schedule		134.94							Fee Schedule											166.87							Fee Schedule		134.94							Fee Schedule		
LUMIGAN 0.01% OPTHL SOLN- 2.5ML	250	RC	A9270	CPT				Both			744.45	335	0.01	670.01	0.01							Fee Schedule		550.89							Fee Schedule																				145.1							Fee Schedule		670.01							Fee Schedule		166.87							Fee Schedule		134.94							Fee Schedule											166.87							Fee Schedule		134.94							Fee Schedule		
LUNELLE 5-25 MG/ 0.5ML INJECTION	250	RC						Both			78.75	35.44	35.44	70.88	51.19							Fee Schedule		58.28							Fee Schedule																													70.88							Fee Schedule																																															
LUNG VOLUMES	460	RC	94727	CPT				Both			283.5	127.58	23.32	318	200							Per Diem		209.79							Fee Schedule											23.32							Fee Schedule											255.15							Fee Schedule																				318							Per Diem																				
LUPRON DEPOT  PWD FOR SUSP 45MG	636	RC	J9217	CPT				Both			46359	20861.55	175.9	41723.1		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	176.2							Fee Schedule		175.9							Fee Schedule		728.64							Fee Schedule											41723.1							Fee Schedule																																															
LUPRON DEPOT 3 MONTH PWD FOR SUSP 22.5MG	636	RC	J9217	CPT				Both			23179.98	10430.99	158.82	20861.98		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	176.2							Fee Schedule		175.9							Fee Schedule		728.64							Fee Schedule		170.78							Fee Schedule		20861.98							Fee Schedule		196.39							Fee Schedule		158.82							Fee Schedule											196.39							Fee Schedule		158.82							Fee Schedule		
LUPRON-DEPOT 22.5 MG KIT	636	RC	J9217	CPT				Both			6180.3	2781.14	158.82	5562.27		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	176.2							Fee Schedule		175.9							Fee Schedule		728.64							Fee Schedule		170.78							Fee Schedule		5562.27							Fee Schedule		196.39							Fee Schedule		158.82							Fee Schedule											196.39							Fee Schedule		158.82							Fee Schedule		
LUPRON-DEPOT 3.75 MG INJECTION	636	RC	J9217	CPT				Both			1633.68	735.16	158.82	1470.31		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	176.2							Fee Schedule		175.9							Fee Schedule		728.64							Fee Schedule		170.78							Fee Schedule		1470.31							Fee Schedule		196.39							Fee Schedule		158.82							Fee Schedule											196.39							Fee Schedule		158.82							Fee Schedule		
LUPRON-DEPOT 30 MG PFS	636	RC	J9217	CPT				Both			7786.8	3504.06	158.82	7008.12		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	176.2							Fee Schedule		175.9							Fee Schedule		728.64							Fee Schedule		170.78							Fee Schedule		7008.12							Fee Schedule		196.39							Fee Schedule		158.82							Fee Schedule											196.39							Fee Schedule		158.82							Fee Schedule		
LUPRON-DEPOT 7.5MG INJ	636	RC	J9217	CPT				Both			1963.5	883.58	158.82	1767.15		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	176.2							Fee Schedule		175.9							Fee Schedule		728.64							Fee Schedule		170.78							Fee Schedule		1767.15							Fee Schedule		196.39							Fee Schedule		158.82							Fee Schedule											196.39							Fee Schedule		158.82							Fee Schedule		
LUPRON-DEPOT PER 1MG	250	RC						Both			91.31	41.09	41.09	196.39	59.35							Fee Schedule		67.57							Fee Schedule																				170.78							Fee Schedule		82.18							Fee Schedule		196.39							Fee Schedule		158.82							Fee Schedule											196.39							Fee Schedule		158.82							Fee Schedule		
LYME DISEASE AB WESTER BLOT 8593 IGG/IGM	302	RC	86618	CPT				Both			184.8	83.16	15.13	166.32	15.13							Fee Schedule		18.92							Fee Schedule		17.54							Fee Schedule		17.03							Fee Schedule											166.32							Fee Schedule																				17.03							Fee Schedule																				
LYME DISEASE ABS BY EIA 6646 IGG/IGM	302	RC	86618	CPT				Both			444.15	199.87	15.13	399.74	15.13							Fee Schedule		18.92							Fee Schedule		17.54							Fee Schedule		17.03							Fee Schedule		17.03							Fee Schedule		399.74							Fee Schedule		19.58							Fee Schedule		15.84							Fee Schedule		17.03							Fee Schedule		19.58							Fee Schedule		15.84							Fee Schedule		
LYME DISEASE ABS W/ REFLEX TO IA 39733	302	RC	86618	CPT				Both			47.58	21.41	15.13	42.82	15.13							Fee Schedule		18.92							Fee Schedule		17.54							Fee Schedule		17.03							Fee Schedule		17.03							Fee Schedule		42.82							Fee Schedule		19.58							Fee Schedule		15.84							Fee Schedule		17.03							Fee Schedule		19.58							Fee Schedule		15.84							Fee Schedule		
LYME DISEASE CSF 15564 0.5 ML	302	RC	86618	CPT				Both			288.75	129.94	15.13	259.88	15.13							Fee Schedule		18.92							Fee Schedule		17.54							Fee Schedule		17.03							Fee Schedule		17.03							Fee Schedule		259.88							Fee Schedule		19.58							Fee Schedule		15.84							Fee Schedule		17.03							Fee Schedule		19.58							Fee Schedule		15.84							Fee Schedule		
LYME DISEASE IGG CSF 70028 IMMUNOBLOT	302	RC	86617	CPT				Both			261	117.45	13.77	234.9	13.77							Fee Schedule		17.21							Fee Schedule		15.95							Fee Schedule		15.49							Fee Schedule		17.03							Fee Schedule		234.9							Fee Schedule		19.58							Fee Schedule		15.84							Fee Schedule		15.49							Fee Schedule		19.58							Fee Schedule		15.84							Fee Schedule		
LYMP INJ ID SNT NODE	340	RC	78195	CPT				Both			1050	472.5	14.41	1097	254.82							Fee Schedule		278.71							Fee Schedule											115.16							Fee Schedule		15.49							Fee Schedule		945							Fee Schedule		17.81							Fee Schedule		14.41							Fee Schedule		1097							Case Rate		17.81							Fee Schedule		14.41							Fee Schedule		
LYMPHAZURIN 1% 10 MG/ML (ISOSULFAN BLUE)	636	RC	A4649	CPT				Both			489.3	220.19	220.19	440.37		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	362.08							Fee Schedule																													440.37							Fee Schedule																																															
LYMPHOCYTE SUBSET PANEL 5 QUEST 8360	302	RC	86361	CPT				Both			120	54	23.8	108	23.8							Fee Schedule		29.75							Fee Schedule		27.58							Fee Schedule		26.78							Fee Schedule											108							Fee Schedule																																															
LYMPHOCYTE T HELP SUPPRESSOR PANEL7924	302	RC	86360	CPT				Both			257.25	115.76	24.91	231.53	41.77							Fee Schedule		52.2							Fee Schedule		48.39							Fee Schedule		46.98							Fee Schedule		26.78							Fee Schedule		231.53							Fee Schedule		30.8							Fee Schedule		24.91							Fee Schedule		46.98							Fee Schedule		30.8							Fee Schedule		24.91							Fee Schedule		
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITHOUT CC/MCC					440	DRG		Inpatient			24992.65	11246.69	11246.69	11246.69							0		No services performed during 15 month lookback period. 				3173.81	2180.75	6008.9	1 through 10									0		No services performed during 15 month lookback period				2506.16	2506.16	2506.16	1 through 10									0		No services provided during 15 month lookback period				23948.47	23948.47	23948.47	1 through 10									0	Fee Schedule	No services provided during 15 month lookback period				2408.59	2408.59	2408.59	1 through 10	Fee Schedule								0		No services provided during 15 month lookback							0		No services provided during 15 month lookback period							0	Fee Schedule	No services provided during 15 month lookback period	
LYNX BLUE SLING SYSTEM #M0068503010	278	RC	C1771	CPT				Both			2985	1343.25	1343.25	2686.5		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	2208.9							Fee Schedule																													2686.5							Fee Schedule																																															
LYSOZYME 619  1 ML SERUM	305	RC	85549	CPT				Both			105	47.25	16.67	94.5	16.67							Fee Schedule		20.83							Fee Schedule		19.31							Fee Schedule		18.75							Fee Schedule											94.5							Fee Schedule																				18.75							Fee Schedule																				
MAALOX MAX SUSPENSION 355ML BTL	250	RC	A9270	CPT				Both			13.65	6.14	0.01	21.56	0.01							Fee Schedule		10.1							Fee Schedule																				18.75							Fee Schedule		12.29							Fee Schedule		21.56							Fee Schedule		17.44							Fee Schedule											21.56							Fee Schedule		17.44							Fee Schedule		
MAALOX PLUS SUSP	250	RC	A9270	CPT				Both			1.58	0.71	0.01	1.42	0.01							Fee Schedule		1.17							Fee Schedule																													1.42							Fee Schedule																																															
MAALOX SUSPENSION	250	RC	A9270	CPT				Both			13.65	6.14	0.01	12.29	0.01							Fee Schedule		10.1							Fee Schedule																													12.29							Fee Schedule																																															
MAALOX TC SUSPENSION 15 ML UD	250	RC	A9270	CPT				Both			1.95	0.88	0.01	1.76	0.01							Fee Schedule		1.44							Fee Schedule																													1.76							Fee Schedule																																															
MAC1 BLADE 301-FO-MAC-1	271	RC						Both			11	4.95	4.95	9.9	7.15							Fee Schedule		8.14							Fee Schedule																													9.9							Fee Schedule																																															
MAC2 BLADE 301-FO-MAC-2	271	RC						Both			11	4.95	4.95	9.9	7.15							Fee Schedule		8.14							Fee Schedule																													9.9							Fee Schedule																																															
MAC3 BLADE 301-FO-MAC-3	271	RC						Both			11	4.95	4.95	9.9	7.15							Fee Schedule		8.14							Fee Schedule																													9.9							Fee Schedule																																															
MAC4 BLADE 301-FO-MAC-4	271	RC						Both			11	4.95	4.95	9.9	7.15							Fee Schedule		8.14							Fee Schedule																													9.9							Fee Schedule																																															
MAG SUL 50% 10ML	636	RC	J3475	CPT				Both			9.45	4.25	0.42	8.51		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	6.99							Fee Schedule		0.46							Fee Schedule		0.42							Fee Schedule											8.51							Fee Schedule																																															
MAG SULFATE 80 MG/50 ML PREMIX	636	RC	J3475	CPT				Both			24.62	11.08	0.41	22.16		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	18.22							Fee Schedule		0.46							Fee Schedule		0.42							Fee Schedule		0.45							Fee Schedule		22.16							Fee Schedule		0.51							Fee Schedule		0.41							Fee Schedule											0.51							Fee Schedule		0.41							Fee Schedule		
MAG SULFATE:5GM/10ML VIALS	636	RC	J3475	CPT				Both			10.5	4.73	0.41	9.45		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	7.77							Fee Schedule		0.46							Fee Schedule		0.42							Fee Schedule		0.45							Fee Schedule		9.45							Fee Schedule		0.51							Fee Schedule		0.41							Fee Schedule											0.51							Fee Schedule		0.41							Fee Schedule		
MAG-AL PLUS XS SUSPENSION  30ML UD	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																				0.45							Fee Schedule		5.67							Fee Schedule		0.51							Fee Schedule		0.41							Fee Schedule											0.51							Fee Schedule		0.41							Fee Schedule		
MAGALDRATE 540 MG/5ML ORAL SUSPENSION UD	250	RC	A9270	CPT				Both			4.2	1.89	0.01	3.78	0.01							Fee Schedule		3.11							Fee Schedule																													3.78							Fee Schedule																																															
MAGIC MOUTHWASH -120ML BOTTLE	250	RC	A9270	CPT				Both			202.65	91.19	0.01	182.39	0.01							Fee Schedule		149.96							Fee Schedule																													182.39							Fee Schedule																																															
MAGNES SULF 5GM/10CC	250	RC						Both			9.45	4.25	4.25	8.51	6.14							Fee Schedule		6.99							Fee Schedule																													8.51							Fee Schedule																																															
MAGNESIUM	301	RC	83735	CPT				Both			124.95	56.23	5.95	112.46	5.95							Fee Schedule		7.44							Fee Schedule		6.9							Fee Schedule		6.7							Fee Schedule											112.46							Fee Schedule																				6.7							Fee Schedule																				
MAGNESIUM CITRATE 10 OZ BOTTLE	250	RC	A9270	CPT				Both			6.3	2.84	0.01	7.71	0.01							Fee Schedule		4.66							Fee Schedule																				6.7							Fee Schedule		5.67							Fee Schedule		7.71							Fee Schedule		6.23							Fee Schedule											7.71							Fee Schedule		6.23							Fee Schedule		
MAGNESIUM OXIDE 400MG (MAG OXIDE) TABLET	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
MAGNESIUM SULF 1 GM/100ML PREMIX	636	RC	J3475	CPT				Both			27	12.15	0.42	24.3		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	19.98							Fee Schedule		0.46							Fee Schedule		0.42							Fee Schedule											24.3							Fee Schedule																																															
MAGNESIUM SULF 1 GM/2 ML INJECTION	636	RC	J3475	CPT				Both			12.6	5.67	0.41	11.34		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	9.32							Fee Schedule		0.46							Fee Schedule		0.42							Fee Schedule		0.45							Fee Schedule		11.34							Fee Schedule		0.51							Fee Schedule		0.41							Fee Schedule											0.51							Fee Schedule		0.41							Fee Schedule		
MAGNESIUM SULF 2GM/50ML PREMIX	636	RC	J3475	CPT				Both			36.75	16.54	0.41	33.08		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	27.2							Fee Schedule		0.46							Fee Schedule		0.42							Fee Schedule		0.45							Fee Schedule		33.08							Fee Schedule		0.51							Fee Schedule		0.41							Fee Schedule											0.51							Fee Schedule		0.41							Fee Schedule		
MAGNESIUM SULFATE  2GM/100 ML IVPB	636	RC	J3475	CPT				Both			36.75	16.54	0.41	33.08		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	27.2							Fee Schedule		0.46							Fee Schedule		0.42							Fee Schedule		0.45							Fee Schedule		33.08							Fee Schedule		0.51							Fee Schedule		0.41							Fee Schedule											0.51							Fee Schedule		0.41							Fee Schedule		
MAGNESIUM SULFATE 20 GMS/500ML  PREMIX	636	RC	J3475	CPT				Both			17.85	8.03	0.41	16.07		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	13.21							Fee Schedule		0.46							Fee Schedule		0.42							Fee Schedule		0.45							Fee Schedule		16.07							Fee Schedule		0.51							Fee Schedule		0.41							Fee Schedule											0.51							Fee Schedule		0.41							Fee Schedule		
MAGNESIUM SULFATE 4 GM/100ML PREMIX	636	RC	J3475	CPT				Both			27.3	12.29	0.41	24.57		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	20.2							Fee Schedule		0.46							Fee Schedule		0.42							Fee Schedule		0.45							Fee Schedule		24.57							Fee Schedule		0.51							Fee Schedule		0.41							Fee Schedule											0.51							Fee Schedule		0.41							Fee Schedule		
MAGNESIUM SULFATE 5 GM/10ML (50%)	636	RC	J3475	CPT				Both			12.6	5.67	0.41	11.34		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	9.32							Fee Schedule		0.46							Fee Schedule		0.42							Fee Schedule		0.45							Fee Schedule		11.34							Fee Schedule		0.51							Fee Schedule		0.41							Fee Schedule											0.51							Fee Schedule		0.41							Fee Schedule		
MAGNESIUM URINE 24 HR 625 6 NHCL 25ML	301	RC	83735	CPT				Both			45.15	20.32	0.41	40.64	5.95							Fee Schedule		7.44							Fee Schedule		6.9							Fee Schedule		6.7							Fee Schedule		0.45							Fee Schedule		40.64							Fee Schedule		0.51							Fee Schedule		0.41							Fee Schedule		6.7							Fee Schedule		0.51							Fee Schedule		0.41							Fee Schedule		
MAGNESIUM URINE 6179 10ml RM TEMP	301	RC	83735	CPT				Both			45.15	20.32	5.95	40.64	5.95							Fee Schedule		7.44							Fee Schedule		6.9							Fee Schedule		6.7							Fee Schedule		6.7							Fee Schedule		40.64							Fee Schedule		7.71							Fee Schedule		6.23							Fee Schedule		6.7							Fee Schedule		7.71							Fee Schedule		6.23							Fee Schedule		
"MAGNESIUM, RBC"	301	RC	83735	CPT				Both			108	48.6	5.95	97.2	5.95							Fee Schedule		7.44							Fee Schedule		6.9							Fee Schedule		6.7							Fee Schedule		6.7							Fee Schedule		97.2							Fee Schedule		7.71							Fee Schedule		6.23							Fee Schedule		6.7							Fee Schedule		7.71							Fee Schedule		6.23							Fee Schedule		
MAGNETIC INSTRUMENT PAD #200-16B	272	RC						Both			10	4.5	4.5	9	6.5							Fee Schedule		7.4							Fee Schedule																				6.7							Fee Schedule		9							Fee Schedule		7.71							Fee Schedule		6.23							Fee Schedule											7.71							Fee Schedule		6.23							Fee Schedule		
MAGONATE 500MG (MAG GLUCONATE)	250	RC	A9270	CPT				Both			1.58	0.71	0.01	1.42	0.01							Fee Schedule		1.17							Fee Schedule																													1.42							Fee Schedule																																															
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC"					441	DRG		Inpatient			34513.36	15531.01	15531.01	15531.01							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback							0		No services provided during 15 month lookback period				6957.97	6957.97	6957.97	1 through 10			
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC"					442	DRG		Inpatient			22966.65	10334.99	10334.99	10334.99							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period							0		No services provided during 15 month lookback period				5711.39	5711.39	5711.39	1 through 10									0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period				3236.29	3236.29	3236.29	1 through 10									0		No services provided during 15 month lookback				8793.21	8793.21	8793.21	1 through 10									0		No services provided during 15 month lookback period	
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC"					443	DRG		Inpatient			19434.39	8745.48	8745.48	8745.48							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period	
DISORDERS OF THE BILIARY TRACT WITH MCC					444	DRG		Inpatient			59077.93	26585.07	26585.07	26585.07							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period	
DISORDERS OF THE BILIARY TRACT WITH CC					445	DRG		Inpatient			23668.04	10650.62	10650.62	10650.62							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period. 				9698.26	9698.26	9698.26	1 through 10									0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback							0		No services provided during 15 month lookback period				5310.59	5310.59	5310.59	1 through 10			
DISORDERS OF THE BILIARY TRACT WITHOUT CC/MCC					446	DRG		Inpatient			33524.97	15086.24	15086.24	15086.24							0		No services performed during 15 month lookback period. 				4218.3	4218.3	4218.3	1 through 10									0		No services performed during 15 month lookback period				3781.68	3781.68	3781.68	1 through 10									0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period	
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKEL					463	DRG		Inpatient			58248.95	26212.03	26212.03	26212.03							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period	
AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE					475	DRG		Inpatient			42453.96	19104.28	19104.28	19104.28							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period	
MAJOR PER ADD 15 MIN	360	RC						Both			367.5	165.38	165.38	330.75	238.88							Fee Schedule		271.95							Fee Schedule																													330.75							Fee Schedule																																															
MAJOR PER HOUR	360	RC						Both			5000	2250	2250	4500	3250							Fee Schedule		3700							Fee Schedule																													4500							Fee Schedule																																															
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH MCC					480	DRG		Inpatient			67292.12	30281.45	30281.45	30281.45							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period	
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH CC					481	DRG		Inpatient			50931.29	22919.08	22919.08	22919.08							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period							0		No services provided during 15 month lookback period				10202.21	10202.21	10202.21	1 through 10									0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period	
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITHOUT CC/MCC					482	DRG		Inpatient			40545.91	18245.66	18245.66	18245.66							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period. 				13889.56	13889.56	13889.56	1 through 10									0		No services provided during 15 month lookback period				10015.9	10015.9	10015.9	1 through 10									0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback				14103.5	14103.5	14103.5	1 through 10									0		No services provided during 15 month lookback period	
KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITH M					485	DRG		Inpatient			52448.07	23601.63	23601.63	23601.63							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period	
MALARIA BLOOD PARASITES 831   1 LAV TUBE	301	RC	87207	CPT				Both			68.25	30.71	5.33	61.43	5.33							Fee Schedule		6.66							Fee Schedule		6.17							Fee Schedule		5.99							Fee Schedule											61.43							Fee Schedule																				5.99							Fee Schedule																				
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND"					493	DRG		Inpatient			46977.42	21139.84	21139.84	21139.84							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0	Fee Schedule	No services provided during 15 month lookback period							0	Fee Schedule	No services provided during 15 month lookback period							0		No services provided during 15 month lookback							0		No services provided during 15 month lookback period							0	Fee Schedule	No services provided during 15 month lookback period	
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND"					494	DRG		Inpatient			46592.79	20966.76	20966.76	20966.76							0		No services performed during 15 month lookback period. 				3254.2	3254.2	3254.2	1 through 10									0		No services performed during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period	
MAMMARY DUCT/GALAC 1	329	RC	77053	CPT				Both			315	141.75	33.07	318	33.07							Fee Schedule		35.91							Fee Schedule											59.37							Fee Schedule											283.5							Fee Schedule																				318							Per Diem																				
MAMMO #11 BIOPSY SITE ID	272	RC						Both			428	192.6	192.6	385.2	278.2							Fee Schedule		316.72							Fee Schedule																													385.2							Fee Schedule																																															
MAMMO #14 BIOPSY SITE ID #MAM3014 (DEVIC	272	RC						Both			278.25	125.21	125.21	250.43	180.86							Fee Schedule		205.91							Fee Schedule																													250.43							Fee Schedule																																															
MAMMO #8 BIOPSY SITE ID	278	RC	A4648	CPT				Both			309.75	139.39	139.39	278.78		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	229.22							Fee Schedule																													278.78							Fee Schedule																																															
MAMMO #8 BIOPSY SITE ID #MAM3008 (DEVICO	272	RC						Both			428	192.6	192.6	385.2	278.2							Fee Schedule		316.72							Fee Schedule																													385.2							Fee Schedule																																															
MAMMO 11G STEREO PROBE #MST11B DEVICOR	272	RC						Both			1550	697.5	697.5	1395	1007.5							Fee Schedule		1147							Fee Schedule																													1395							Fee Schedule																																															
MAMMO 11G. BLADED EX PRB. #HH11BEX (J&J)	272	RC						Both			830.55	373.75	373.75	747.5	539.86							Fee Schedule		614.61							Fee Schedule																													747.5							Fee Schedule																																															
MAMMO 2/3D DIAG BILAT TOMO	401	RC	G0279	CPT				Both			94.5	42.53	20.02	478	25.04							Fee Schedule	Not Reimbursed	22.73							Fee Schedule											20.02							Fee Schedule											85.05							Fee Schedule																				478							Case Rate																				
MAMMO 2/3D DIAG UNILAT TOMO	401	RC	G0279	CPT				Both			94.5	42.53	20.02	478	25.04							Fee Schedule	Not Reimbursed	22.73							Fee Schedule											20.02							Fee Schedule											85.05							Fee Schedule																				478							Case Rate																				
MAMMO 2/3D SCR BILAT TOMO	403	RC	77063	CPT				Both			94.5	42.53	18.67	478	20.67							Fee Schedule	Not Reimbursed	22.73							Fee Schedule											18.67							Fee Schedule											85.05							Fee Schedule																				478							Case Rate																				
MAMMO 8G. BLADED EX PRB. #HH8BEX (J&J)	272	RC						Both			813.75	366.19	366.19	732.38	528.94							Fee Schedule		602.18							Fee Schedule																													732.38							Fee Schedule																																															
MAMMO 8G. BLADELESS PROBE #MRP08S	272	RC						Both			1278	575.1	575.1	1150.2	830.7							Fee Schedule		945.72							Fee Schedule																													1150.2							Fee Schedule																																															
MAMMO BLADELESS PROBE #MRP08X	272	RC						Both			1253.7	564.17	564.17	1128.33	814.91							Fee Schedule		927.74							Fee Schedule																													1128.33							Fee Schedule																																															
MAMMO BREAST BIOPSY CLIP 861217 PERIPH	272	RC	A4648	CPT				Both			237	106.65	95.02	213.3	95.02							Fee Schedule		175.38							Fee Schedule																													213.3							Fee Schedule																																															
MAMMO COREDISH	270	RC						Both			20	9	9	18	13							Fee Schedule		14.8							Fee Schedule																													18							Fee Schedule																																															
MAMMO FFDM DIAG BILAT	401	RC	77066	CPT				Both			472.5	212.63	88.85	478	300							Per Diem		108.32							Fee Schedule											88.85							Fee Schedule											425.25							Fee Schedule																				478							Case Rate																				
MAMMO FFDM DIAG UNILAT	401	RC	77065	CPT				Both			472.5	212.63	69.43	478	300							Per Diem		84.61							Fee Schedule											69.43							Fee Schedule											425.25							Fee Schedule																				478							Case Rate																				
MAMMO FFDM SCR BILAT	403	RC	77067	CPT				Both			472.5	212.63	73.36	478	300							Per Diem		89.49							Fee Schedule											73.36							Fee Schedule											425.25							Fee Schedule																				478							Case Rate																				
MAMMO HOOKWIRE  ADDITIONAL LESION	320	RC	19282	CPT				Both			2100	945	55.42	1890	55.42							Fee Schedule		1554							Fee Schedule																													1890							Fee Schedule																				318							Per Diem																				
MAMMO HOOKWIRE 1ST LESION	320	RC	19281	CPT				Both			2100	945	110.48	1890	110.48							Fee Schedule		1554							Fee Schedule																													1890							Fee Schedule																				318							Per Diem																				
MAMMO MR PILLAR & POST #MRK303  (J&J)	272	RC						Both			2126.25	956.81	956.81	1913.63	1382.06							Fee Schedule		1573.43							Fee Schedule																													1913.63							Fee Schedule																																															
MAMMO MR PILLAR & POST #MRK304  (J&J)	272	RC						Both			2126.25	956.81	956.81	1913.63	1382.06							Fee Schedule		1573.43							Fee Schedule																													1913.63							Fee Schedule																																															
MAMMO PILLAR&POST 8G MRT08S (J &J)	272	RC						Both			1162.35	523.06	523.06	1046.12	755.53							Fee Schedule		860.14							Fee Schedule																													1046.12							Fee Schedule																																															
MAMMO PILLAR&POST 8G MRT08X (J &J)	272	RC						Both			892.5	401.63	401.63	803.25	580.13							Fee Schedule		660.45							Fee Schedule																													803.25							Fee Schedule																																															
MAMMO PROBE GUIDE 11G #GO11LF	272	RC						Both			43	19.35	19.35	38.7	27.95							Fee Schedule		31.82							Fee Schedule																													38.7							Fee Schedule																																															
MAMMO PROBE GUIDE 8G #GO8LF  ( DEVICOR	272	RC						Both			35	15.75	15.75	31.5	22.75							Fee Schedule		25.9							Fee Schedule																													31.5							Fee Schedule																																															
MAMMO PROCEDURE KIT #MUK304   (J &J)	272	RC						Both			2126.25	956.81	956.81	1913.63	1382.06							Fee Schedule		1573.43							Fee Schedule																													1913.63							Fee Schedule																																															
MAMMO R2 CAD SCREENING	403	RC	77067	CPT				Both			78.75	35.44	35.44	478	81.97							Fee Schedule	Not Reimbursed	89.49							Fee Schedule											73.36							Fee Schedule											70.88							Fee Schedule																				478							Case Rate																				
MAMMO REVOLVE 8G STEREO PROBE MST0812	272	RC						Both			1258	566.1	566.1	1132.2	817.7							Fee Schedule		930.92							Fee Schedule																													1132.2							Fee Schedule																																															
MAMMO SURGICAL SPECIMEN	329	RC	76098	CPT				Both			315	141.75	7.16	318	7.16							Fee Schedule		7.66							Fee Schedule											11.95							Fee Schedule											283.5							Fee Schedule																				318							Per Diem																				
MAMMO TARGET SET MRT08X	272	RC						Both			1253.7	564.17	564.17	1128.33	814.91							Fee Schedule		927.74							Fee Schedule																													1128.33							Fee Schedule																																															
MAMMO UNIVERSAL TARGET #MRU08S	272	RC						Both			1185	533.25	533.25	1066.5	770.25							Fee Schedule		876.9							Fee Schedule																													1066.5							Fee Schedule																																															
MAMMO UNIVESAL BX. KIT # MUK303  (J &J)	272	RC						Both			2126.25	956.81	956.81	1913.63	1382.06							Fee Schedule		1573.43							Fee Schedule																													1913.63							Fee Schedule																																															
MAMMO UNIVESAL TARGET #MRU08X	272	RC						Both			1244.25	559.91	559.91	1119.83	808.76							Fee Schedule		920.75							Fee Schedule																													1119.83							Fee Schedule																																															
MAMMO VACUUM SET #MVAC1  (DEVICOR	272	RC						Both			103	46.35	46.35	92.7	66.95							Fee Schedule		76.22							Fee Schedule																													92.7							Fee Schedule																																															
MAMMO/STEREO GUIDED BIOPSY ADDITIONAL	320	RC	19082	CPT				Both			2100	945	92.3	1890	92.3							Fee Schedule		1554							Fee Schedule																													1890							Fee Schedule																				318							Per Diem																				
MAMMOMARK BX SITE ID 8G BOWTIE MMK0801	278	RC	A4648	CPT				Both			428	192.6	192.6	385.2		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	316.72							Fee Schedule																													385.2							Fee Schedule																																															
MAMMOMARK TRIPLE TWIST 8G MMK0803	278	RC	A4648	CPT				Both			386	173.7	173.7	347.4		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	285.64							Fee Schedule																													347.4							Fee Schedule																																															
MAMMOSTAR BX ID BARBELL 8G STAR0833	278	RC	A4648	CPT				Both			397	178.65	178.65	357.3		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	293.78							Fee Schedule																													357.3							Fee Schedule																																															
MANDIBLE 4V	320	RC	70110	CPT				Both			315	141.75	17.71	318	20.55							Fee Schedule		24.87							Fee Schedule											17.71							Fee Schedule											283.5							Fee Schedule																				318							Per Diem																				
MANDOL 1 GM VIAL	250	RC						Both			30.2	13.59	13.59	27.18	19.63							Fee Schedule		22.35							Fee Schedule																													27.18							Fee Schedule																																															
MANDOL PER GM ADV	250	RC						Both			56.45	25.4	25.4	50.81	36.69							Fee Schedule		41.77							Fee Schedule																													50.81							Fee Schedule																																															
MANDOL VL 1GM 10ML	250	RC						Both			28.55	12.85	12.85	25.7	18.56							Fee Schedule		21.13							Fee Schedule																													25.7							Fee Schedule																																															
MANGANESE 626	301	RC	83785	CPT				Both			136.5	61.43	21.87	122.85	21.87							Fee Schedule		27.33							Fee Schedule		27.45							Fee Schedule		26.65							Fee Schedule											122.85							Fee Schedule																				26.65							Fee Schedule																				
MANIFOLD FOR NEPTUNE 0702-020-000	272	RC						Both			52.5	23.63	23.63	47.25	34.13							Fee Schedule		38.85							Fee Schedule																				26.65							Fee Schedule		47.25							Fee Schedule		30.65							Fee Schedule		24.78							Fee Schedule											30.65							Fee Schedule		24.78							Fee Schedule		
MANNITOL 20% 50GM/250ML PREMIX	636	RC	J3490	CPT				Both			79.56	35.8	35.8	71.6		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	58.87							Fee Schedule																													71.6							Fee Schedule																																															
MANNITOL 25% 50 ML	636	RC	J2150	CPT				Both			12.6	5.67	5.67	11.34		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	9.32							Fee Schedule																													11.34							Fee Schedule																																															
MANNITOL 50CC	636	RC	J2150	CPT				Both			5.25	2.36	2.36	4.73		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	3.89							Fee Schedule																													4.73							Fee Schedule																																															
MANUKA SUPER LITE 4X5  #MM0071	272	RC	A6197	CPT				Both			23	10.35	10.35	24.14	14.8							Fee Schedule		17.02							Fee Schedule		24.14							Fee Schedule		18.5							Fee Schedule											20.7							Fee Schedule																																															
MARCAINE 0.25 % 50 ML VIAL ( PER ML)	250	RC	J0665	CPT				Both			9.45	4.25	0.01	26.96	6.14							Fee Schedule		6.99							Fee Schedule		0.01							Fee Schedule											23.44							Fee Schedule		8.51							Fee Schedule		26.96							Fee Schedule		21.8							Fee Schedule											26.96							Fee Schedule		21.8							Fee Schedule		
MARCAINE 0.25% 30ML (SENSORCAINE) MPF	250	RC	J0665	CPT				Both			10.8	4.86	0.01	9.72	7.02							Fee Schedule		7.99							Fee Schedule		0.01							Fee Schedule											0.01							Fee Schedule		9.72							Fee Schedule		0.01							Fee Schedule		0.01							Fee Schedule											0.01							Fee Schedule		0.01							Fee Schedule		
MARCAINE 0.25% 50 ML MDV  ( PER ML)	250	RC	J0665	CPT				Both			6.3	2.84	0.01	5.67	4.1							Fee Schedule		4.66							Fee Schedule		0.01							Fee Schedule											0.01							Fee Schedule		5.67							Fee Schedule		0.01							Fee Schedule		0.01							Fee Schedule											0.01							Fee Schedule		0.01							Fee Schedule		
MARCAINE 0.5% / EPI  MDV  50 ML	250	RC	J0665	CPT				Both			6.3	2.84	0.01	5.67	4.1							Fee Schedule		4.66							Fee Schedule		0.01							Fee Schedule											0.01							Fee Schedule		5.67							Fee Schedule		0.01							Fee Schedule		0.01							Fee Schedule											0.01							Fee Schedule		0.01							Fee Schedule		
MARCAINE 0.5% / EPI  SDV  30 ML PF	250	RC	J0665	CPT				Both			46.92	21.11	0.01	42.23	30.5							Fee Schedule		34.72							Fee Schedule		0.01							Fee Schedule											0.01							Fee Schedule		42.23							Fee Schedule		0.01							Fee Schedule		0.01							Fee Schedule											0.01							Fee Schedule		0.01							Fee Schedule		
MARCAINE 0.5% 50 ML MDV  (PER ML)	250	RC	J0665	CPT				Both			9.45	4.25	0.01	8.51	6.14							Fee Schedule		6.99							Fee Schedule		0.01							Fee Schedule											0.01							Fee Schedule		8.51							Fee Schedule		0.01							Fee Schedule		0.01							Fee Schedule											0.01							Fee Schedule		0.01							Fee Schedule		
MARCAINE 0.5% MPF (SENSORCAINE) 30ML	250	RC						Both			6.3	2.84	0.01	5.67	4.1							Fee Schedule		4.66							Fee Schedule																				0.01							Fee Schedule		5.67							Fee Schedule		0.01							Fee Schedule		0.01							Fee Schedule											0.01							Fee Schedule		0.01							Fee Schedule		
MARCAINE 0.5% MPF 30ML (SENSORCAINE)	250	RC	J0665	CPT				Both			10.62	4.78	0.01	9.56	6.9							Fee Schedule		7.86							Fee Schedule		0.01							Fee Schedule																				9.56							Fee Schedule																																															
MARCAINE 0.5% MPF-10 ML SDV	250	RC	J0665	CPT				Both			9.96	4.48	0.01	8.96	6.47							Fee Schedule		7.37							Fee Schedule		0.01							Fee Schedule											0.01							Fee Schedule		8.96							Fee Schedule		0.01							Fee Schedule		0.01							Fee Schedule											0.01							Fee Schedule		0.01							Fee Schedule		
"MARIJUANA METABOLITE, QUANT, UR 26514"	301	RC	80349	CPT				Both			116.46	52.41	0.01	104.81	0.01							Fee Schedule									Other	No Additional Reimbursement 																			0.01							Fee Schedule		104.81							Fee Schedule		0.01							Fee Schedule		0.01							Fee Schedule											0.01							Fee Schedule		0.01							Fee Schedule		
MARYLAND BIPOLAR FORCEPS 471172(14 USES)	270	RC						Both			740	333	333	666	481							Fee Schedule		547.6							Fee Schedule																													666							Fee Schedule																																															
MASIMO MULTISITE WRAP #1597 ST. ROBBINS	271	RC						Both			3	1.35	1.35	2.7	1.95							Fee Schedule		2.22							Fee Schedule																													2.7							Fee Schedule																																															
MASIMO NEONATAL SENSOR NEO-L 1862	270	RC						Both			16	7.2	7.2	14.4	10.4							Fee Schedule		11.84							Fee Schedule																													14.4							Fee Schedule																																															
MASIMO PULSE OX INFANT PROBE 2328	270	RC						Both			17	7.65	7.65	15.3	11.05							Fee Schedule		12.58							Fee Schedule																													15.3							Fee Schedule																																															
MASIMO PULSE OX PROBE 1869	270	RC						Both			595.35	267.91	267.91	535.82	386.98							Fee Schedule		440.56							Fee Schedule																													535.82							Fee Schedule																																															
MASK AEROSOL PEDIATRIC 301-171	271	RC						Both			2	0.9	0.9	1.8	1.3							Fee Schedule		1.48							Fee Schedule																													1.8							Fee Schedule																																															
MASK ANESTHESIA ADULT #6850	271	RC						Both			5.25	2.36	2.36	4.73	3.41							Fee Schedule		3.89							Fee Schedule																													4.73							Fee Schedule																																															
MASK CHILD VITAL SIGNS 6840	271	RC						Both			5	2.25	2.25	4.5	3.25							Fee Schedule		3.7							Fee Schedule																													4.5							Fee Schedule																																															
MASK CONCENTRATION OXYGEN PED  HUD1035	271	RC						Both			3	1.35	1.35	2.7	1.95							Fee Schedule		2.22							Fee Schedule																													2.7							Fee Schedule																																															
MASK DINOSAUR NEBULIZER #0312 (TRIANIM)	271	RC						Both			6	2.7	2.7	5.4	3.9							Fee Schedule		4.44							Fee Schedule																													5.4							Fee Schedule																																															
MASK FULL FACE BIPAP NIVAIRO MED  RT045M	270	RC	A7030	CPT				Both			78.75	35.44	35.44	113.87	69.06							Fee Schedule		58.28							Fee Schedule		113.87							Fee Schedule																				70.88							Fee Schedule																																															
MASK FULL FACE BIPAP NIVAIRO SML  RT045S	270	RC	A7030	CPT				Both			78.75	35.44	35.44	127.13	69.06							Fee Schedule		58.28							Fee Schedule		113.87							Fee Schedule											110.55							Fee Schedule		70.88							Fee Schedule		127.13							Fee Schedule		102.81							Fee Schedule											127.13							Fee Schedule		102.81							Fee Schedule		
MASK KIMBERLY CLARK (LAZER) 47650	271	RC						Both			1.05	0.47	0.47	127.13	0.68							Fee Schedule		0.78							Fee Schedule																				110.55							Fee Schedule		0.95							Fee Schedule		127.13							Fee Schedule		102.81							Fee Schedule											127.13							Fee Schedule		102.81							Fee Schedule		
MASK LARYNGEAL #1 329100000U	272	RC						Both			20.6	9.27	9.27	18.54	13.39							Fee Schedule		15.24							Fee Schedule																													18.54							Fee Schedule																																															
MASK LARYNGEAL #1 329150000U	272	RC						Both			21	9.45	9.45	18.9	13.65							Fee Schedule		15.54							Fee Schedule																													18.9							Fee Schedule																																															
MASK LARYNGEAL DISP. #LM-321-400 (SHARN)	272	RC						Both			51.45	23.15	23.15	46.31	33.44							Fee Schedule		38.07							Fee Schedule																													46.31							Fee Schedule																																															
MASK MED. CONC. 102-E (301-180EA)	271	RC						Both			3	1.35	1.35	2.7	1.95							Fee Schedule		2.22							Fee Schedule																													2.7							Fee Schedule																																															
MASK MED. CONC.PED. #222-E *DISCON.*	271	RC						Both			4.2	1.89	1.89	3.78	2.73							Fee Schedule		3.11							Fee Schedule																													3.78							Fee Schedule																																															
MASK N95 ISOLATION REGULAR #1860	270	RC						Both			33.6	15.12	15.12	30.24	21.84							Fee Schedule		24.86							Fee Schedule																													30.24							Fee Schedule																																															
MASK N95 ISOLATION SMALL #1860S	270	RC						Both			34	15.3	15.3	30.6	22.1							Fee Schedule		25.16							Fee Schedule																													30.6							Fee Schedule																																															
MASK PREFORMATRAK - MED. #73-1018593	271	RC						Both			84	37.8	37.8	75.6	54.6							Fee Schedule		62.16							Fee Schedule																													75.6							Fee Schedule																																															
MASK PREFORMATRAK LG. #73-1018594 (TRIAN	271	RC						Both			101.85	45.83	45.83	91.67	66.2							Fee Schedule		75.37							Fee Schedule																													91.67							Fee Schedule																																															
MASK PREFORMATRAK SML. #73-1018892 (TRIA	271	RC						Both			101.85	45.83	45.83	91.67	66.2							Fee Schedule		75.37							Fee Schedule																													91.67							Fee Schedule																																															
MASK SURGICAL 49235 GREEN (SENECA)	271	RC						Both			2.1	0.95	0.95	1.89	1.37							Fee Schedule		1.55							Fee Schedule																													1.89							Fee Schedule																																															
MASK TREATMENT #1083  (SENECA)	271	RC						Both			7.35	3.31	3.31	6.62	4.78							Fee Schedule		5.44							Fee Schedule																													6.62							Fee Schedule																																															
MASK TREATMENT #1088  (SENECA)	271	RC						Both			4.2	1.89	1.89	3.78	2.73							Fee Schedule		3.11							Fee Schedule																													3.78							Fee Schedule																																															
MASK TX. PEDIATRIC #1085	271	RC						Both			2	0.9	0.9	1.8	1.3							Fee Schedule		1.48							Fee Schedule																													1.8							Fee Schedule																																															
MASK VITAL SIGN TODDLER 6830	271	RC						Both			7	3.15	3.15	6.3	4.55							Fee Schedule		5.18							Fee Schedule																													6.3							Fee Schedule																																															
SOFT TISSUE PROCEDURES WITH CC					501	DRG		Inpatient			49500.55	22275.25	22275.25	22275.25							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period. 				12772.83	12772.83	12772.83	1 through 10									0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period	
MASTER LAVAGE DISPOS	271	RC						Both			196.35	88.36	88.36	176.72	127.63							Fee Schedule		145.3							Fee Schedule																													176.72							Fee Schedule																																															
MASTISOL ADHESIVE AMPULE VIALS 2/3CC	270	RC	A4364	CPT				Both			5.25	2.36	2.34	4.73	2.34							Fee Schedule		3.89							Fee Schedule		3.84							Fee Schedule		2.93							Fee Schedule											4.73							Fee Schedule																																															
MASTOID BILAT	320	RC	70130	CPT				Both			315	141.75	3.47	318	30.15							Fee Schedule		36.23							Fee Schedule											22.35							Fee Schedule		3.73							Fee Schedule		283.5							Fee Schedule		4.29							Fee Schedule		3.47							Fee Schedule		318							Per Diem		4.29							Fee Schedule		3.47							Fee Schedule		
MATERNIMATE HYDROGEL DRESSING	272	RC						Both			23.1	10.4	10.4	20.79	15.02							Fee Schedule		17.09							Fee Schedule																													20.79							Fee Schedule																																															
MATRION 20MM DISK #PAC20MM	278	RC	Q4201	CPT				Both			600	270	130.95	540		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	444							Fee Schedule		130.95							Fee Schedule																				540							Fee Schedule																																															
MAXAIRE INHALER	636	RC	J3535	CPT				Both			477.44	214.85	118.24	429.7		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	353.31							Fee Schedule																				127.14							Fee Schedule		429.7							Fee Schedule		146.21							Fee Schedule		118.24							Fee Schedule											146.21							Fee Schedule		118.24							Fee Schedule		
MAXAQUIN:400 MG TABS	250	RC	A9270	CPT				Both			18.9	8.51	0.01	17.01	0.01							Fee Schedule		13.99							Fee Schedule																													17.01							Fee Schedule																																															
MAXZIDE 75/50 TABS	250	RC	A9270	CPT				Both			4.2	1.89	0.01	3.78	0.01							Fee Schedule		3.11							Fee Schedule																													3.78							Fee Schedule																																															
MAYO COVERS #DYNJP2500	272	RC						Both			3	1.35	1.35	2.7	1.95							Fee Schedule		2.22							Fee Schedule																													2.7							Fee Schedule																																															
MCGRATH DISP. BLADE SIZE #3  350-005-000	272	RC						Both			44	19.8	19.8	39.6	28.6							Fee Schedule		32.56							Fee Schedule																													39.6							Fee Schedule																																															
MCGRATH DISP. BLADE SIZE #4  350-013-000	272	RC						Both			42	18.9	18.9	37.8	27.3							Fee Schedule		31.08							Fee Schedule																													37.8							Fee Schedule																																															
MCGRATH DISP. LARYNGO BLADE X3-003-000	272	RC						Both			138	62.1	62.1	124.2	89.7							Fee Schedule		102.12							Fee Schedule																													124.2							Fee Schedule																																															
MEASLES ANTIBODY IGM 34256	302	RC	86765	CPT				Both			102	45.9	11.45	91.8	11.45							Fee Schedule		14.31							Fee Schedule		13.27							Fee Schedule		12.88							Fee Schedule											91.8							Fee Schedule																				12.88							Fee Schedule																				
MECLIZINE 12.5MG (ANTIVERT) TABLET	250	RC	A9270	CPT				Both			6.3	2.84	0.01	14.81	0.01							Fee Schedule		4.66							Fee Schedule																				12.88							Fee Schedule		5.67							Fee Schedule		14.81							Fee Schedule		11.98							Fee Schedule											14.81							Fee Schedule		11.98							Fee Schedule		
MECLIZINE 25MG (ANTIVERT) TABLET	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
MECONIUM SUCTION DEVICE 3.0	272	RC						Both			30.45	13.7	13.7	27.41	19.79							Fee Schedule		22.53							Fee Schedule																													27.41							Fee Schedule																																															
MED CHECK STEAM INTEGRATOR MDS200600	270	RC						Both			1	0.45	0.45	0.9	0.65							Fee Schedule		0.74							Fee Schedule																													0.9							Fee Schedule																																															
MEDARTIS 2.0 RADIAL HEAD PLATE A-4656.68	278	RC	C1713	CPT				Both			4011	1804.95	1804.95	3609.9		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	2968.14							Fee Schedule																													3609.9							Fee Schedule																																															
MEDARTIS 2.8MM LOCKING PLATE A-4850.69	278	RC	C1713	CPT				Both			4380	1971	1971	3942		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	3241.2							Fee Schedule																													3942							Fee Schedule																																															
MEDARTIS 2.8X18MM SCREW A-5850.18/1	278	RC	C1713	CPT				Both			507	228.15	228.15	456.3		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	375.18							Fee Schedule																													456.3							Fee Schedule																																															
MEDARTIS 2.8X20MM SCREW A-5850.20/1	278	RC	C1713	CPT				Both			507	228.15	228.15	456.3		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	375.18							Fee Schedule																													456.3							Fee Schedule																																															
MEDARTIS 2.8X22MM SCREW A-5800.22/1	278	RC	C1713	CPT				Both			309	139.05	139.05	278.1		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	228.66							Fee Schedule																													278.1							Fee Schedule																																															
MEDARTIS 2.8X22MM SCREW A-5850.22/1	278	RC	C1713	CPT				Both			507	228.15	228.15	456.3		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	375.18							Fee Schedule																													456.3							Fee Schedule																																															
MEDARTIS 2.8X24MM SCREW A-5800.24/1	278	RC	C1713	CPT				Both			309	139.05	139.05	278.1		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	228.66							Fee Schedule																													278.1							Fee Schedule																																															
MEDARTIS 2.8X24MM SCREW A-5850.24/1	278	RC	C1713	CPT				Both			507	228.15	228.15	456.3		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	375.18							Fee Schedule																													456.3							Fee Schedule																																															
MEDARTIS 2.8X26MM SCREW A-5800.26/1	278	RC	C1713	CPT				Both			309	139.05	139.05	278.1		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	228.66							Fee Schedule																													278.1							Fee Schedule																																															
MEDARTIS 2.8X26MM SCREW A-5850.26/1	278	RC	C1713	CPT				Both			507	228.15	228.15	456.3		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	375.18							Fee Schedule																													456.3							Fee Schedule																																															
MEDARTIS 2.8X32MM SCREW A-5800.32/1	278	RC	C1713	CPT				Both			309	139.05	139.05	278.1		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	228.66							Fee Schedule																													278.1							Fee Schedule																																															
MEDARTIS 2.8X32MM SCREW A-5850.32/1	278	RC	C1713	CPT				Both			507	228.15	228.15	456.3		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	375.18							Fee Schedule																													456.3							Fee Schedule																																															
MEDARTIS 2.8X34MM SCREW A-5800.34/1	278	RC	C1713	CPT				Both			309	139.05	139.05	278.1		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	228.66							Fee Schedule																													278.1							Fee Schedule																																															
MEDARTIS 2.8X36MM SCREW A-5800.36/1	278	RC	C1713	CPT				Both			309	139.05	139.05	278.1		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	228.66							Fee Schedule																													278.1							Fee Schedule																																															
MEDARTIS 2.8X70MM SCREW A-5800.70/1	278	RC	C1713	CPT				Both			309	139.05	139.05	278.1		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	228.66							Fee Schedule																													278.1							Fee Schedule																																															
MEDARTIS 2HOOK PLATE A-4200.40	278	RC	C1713	CPT				Both			1293	581.85	581.85	1163.7		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	956.82							Fee Schedule																													1163.7							Fee Schedule																																															
MEDARTIS 3.0 CANN COMP SCREW A-5881.28/1	278	RC	C1713	CPT				Both			1116	502.2	502.2	1004.4		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	825.84							Fee Schedule																													1004.4							Fee Schedule																																															
MEDARTIS 3.0 CANN COMP SCREW A-5881.30/1	278	RC	C1713	CPT				Both			1116	502.2	502.2	1004.4		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	825.84							Fee Schedule																													1004.4							Fee Schedule																																															
MEDARTIS 4HOOK PLATE A-4200.41	278	RC	C1713	CPT				Both			1440	648	648	1296		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1065.6							Fee Schedule																													1296							Fee Schedule																																															
MEDARTIS BONE SCREW A-5200.07/1	278	RC	C1713	CPT				Both			309	139.05	139.05	278.1		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	228.66							Fee Schedule																													278.1							Fee Schedule																																															
MEDARTIS BONE SCREW A-5200.09/1	278	RC	C1713	CPT				Both			309	139.05	139.05	278.1		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	228.66							Fee Schedule																													278.1							Fee Schedule																																															
MEDARTIS BONE SCREW A-5400.04/1	278	RC	C1713	CPT				Both			309	139.05	139.05	278.1		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	228.66							Fee Schedule																													278.1							Fee Schedule																																															
MEDARTIS BONE SCREW A-5400.05/1	278	RC	C1713	CPT				Both			309	139.05	139.05	278.1		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	228.66							Fee Schedule																													278.1							Fee Schedule																																															
MEDARTIS BONE SCREW A-5400.06/1	278	RC	C1713	CPT				Both			309	139.05	139.05	278.1		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	228.66							Fee Schedule																													278.1							Fee Schedule																																															
MEDARTIS BONE SCREW A-5400.07/1	278	RC	C1713	CPT				Both			309	139.05	139.05	278.1		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	228.66							Fee Schedule																													278.1							Fee Schedule																																															
MEDARTIS BONE SCREW A-5400.08/1	278	RC	C1713	CPT				Both			309	139.05	139.05	278.1		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	228.66							Fee Schedule																													278.1							Fee Schedule																																															
MEDARTIS BONE SCREW A-5400.08/1	278	RC	C1713	CPT				Both			309	139.05	139.05	278.1		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	228.66							Fee Schedule																													278.1							Fee Schedule																																															
MEDARTIS BONE SCREW A-5400.09/1	278	RC	C1713	CPT				Both			309	139.05	139.05	278.1		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	228.66							Fee Schedule																													278.1							Fee Schedule																																															
MEDARTIS BONE SCREW A-5400.10/1	278	RC	C1713	CPT				Both			309	139.05	139.05	278.1		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	228.66							Fee Schedule																													278.1							Fee Schedule																																															
MEDARTIS BONE SCREW A-5400.11/1	278	RC	C1713	CPT				Both			309	139.05	139.05	278.1		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	228.66							Fee Schedule																													278.1							Fee Schedule																																															
MEDARTIS BONE SCREW A-5400.12/1	278	RC	C1713	CPT				Both			309	139.05	139.05	278.1		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	228.66							Fee Schedule																													278.1							Fee Schedule																																															
MEDARTIS BONE SCREW A-5400.13/1	278	RC	C1713	CPT				Both			309	139.05	139.05	278.1		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	228.66							Fee Schedule																													278.1							Fee Schedule																																															
MEDARTIS BONE SCREW A-5400.14/1	278	RC	C1713	CPT				Both			309	139.05	139.05	278.1		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	228.66							Fee Schedule																													278.1							Fee Schedule																																															
MEDARTIS BONE SCREW A-5400.15/1	278	RC	C1713	CPT				Both			309	139.05	139.05	278.1		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	228.66							Fee Schedule																													278.1							Fee Schedule																																															
MEDARTIS BONE SCREW A-5400.16/1	278	RC	C1713	CPT				Both			309	139.05	139.05	278.1		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	228.66							Fee Schedule																													278.1							Fee Schedule																																															
MEDARTIS BONE SCREW A-5400.17/1	278	RC	C1713	CPT				Both			309	139.05	139.05	278.1		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	228.66							Fee Schedule																													278.1							Fee Schedule																																															
MEDARTIS BONE SCREW A-5400.18/1	278	RC	C1713	CPT				Both			309	139.05	139.05	278.1		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	228.66							Fee Schedule																													278.1							Fee Schedule																																															
MEDARTIS BONE SCREW A-5400.19/1	278	RC	C1713	CPT				Both			309	139.05	139.05	278.1		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	228.66							Fee Schedule																													278.1							Fee Schedule																																															
MEDARTIS BONE SCREW A-5400.20/1	278	RC	C1713	CPT				Both			309	139.05	139.05	278.1		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	228.66							Fee Schedule																													278.1							Fee Schedule																																															
MEDARTIS BONE SCREW A-5400.21/1	278	RC	C1713	CPT				Both			309	139.05	139.05	278.1		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	228.66							Fee Schedule																													278.1							Fee Schedule																																															
MEDARTIS BONE SCREW A-5400.22/1	278	RC	C1713	CPT				Both			309	139.05	139.05	278.1		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	228.66							Fee Schedule																													278.1							Fee Schedule																																															
MEDARTIS BONE SCREW A-5400.23/1	278	RC	C1713	CPT				Both			309	139.05	139.05	278.1		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	228.66							Fee Schedule																													278.1							Fee Schedule																																															
MEDARTIS BONE SCREW A-5400.24/1	278	RC	C1713	CPT				Both			309	139.05	139.05	278.1		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	228.66							Fee Schedule																													278.1							Fee Schedule																																															
MEDARTIS CANN. SCREW 14MM A-5880.14/1	278	RC	C1713	CPT				Both			1116	502.2	502.2	1004.4		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	825.84							Fee Schedule																													1004.4							Fee Schedule																																															
MEDARTIS CANN. SCREW 16MM A-5880.16/1	278	RC	C1713	CPT				Both			1116	502.2	502.2	1004.4		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	825.84							Fee Schedule																													1004.4							Fee Schedule																																															
MEDARTIS CANN. SCREW 20MM A-5780.20/1	278	RC	C1713	CPT				Both			1068	480.6	480.6	961.2		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	790.32							Fee Schedule																													961.2							Fee Schedule																																															
MEDARTIS CANN. SCREW 20MM A-5880.20/1	278	RC	C1713	CPT				Both			1116	502.2	502.2	1004.4		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	825.84							Fee Schedule																													1004.4							Fee Schedule																																															
MEDARTIS COMPRESSION PLATE A-4645.01	278	RC	C1713	CPT				Both			1287	579.15	579.15	1158.3		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	952.38							Fee Schedule																													1158.3							Fee Schedule																																															
MEDARTIS COMPRESSION PLATE A-4645.02	278	RC	C1713	CPT				Both			1287	579.15	579.15	1158.3		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	952.38							Fee Schedule																													1158.3							Fee Schedule																																															
MEDARTIS COMPRESSION PLATE A-4645.03	278	RC	C1713	CPT				Both			1287	579.15	579.15	1158.3		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	952.38							Fee Schedule																													1158.3							Fee Schedule																																															
MEDARTIS COMPRESSION PLATE A-4645.08	278	RC	C1713	CPT				Both			1455	654.75	654.75	1309.5		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1076.7							Fee Schedule																													1309.5							Fee Schedule																																															
MEDARTIS COMPRESSION PLATE A-4645.10	278	RC	C1713	CPT				Both			1164	523.8	523.8	1047.6		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	861.36							Fee Schedule																													1047.6							Fee Schedule																																															
MEDARTIS COMPRESSION PLATE A-4645.16	278	RC	C1713	CPT				Both			1575	708.75	708.75	1417.5		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1165.5							Fee Schedule																													1417.5							Fee Schedule																																															
MEDARTIS COMPRESSION PLATE A-4645.20	278	RC	C1713	CPT				Both			1164	523.8	523.8	1047.6		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	861.36							Fee Schedule																													1047.6							Fee Schedule																																															
MEDARTIS COMPRESSION PLATE A-4645.21	278	RC	C1713	CPT				Both			1164	523.8	523.8	1047.6		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	861.36							Fee Schedule																													1047.6							Fee Schedule																																															
MEDARTIS COMPRESSION PLATE A-4645.22	278	RC	C1713	CPT				Both			1575	708.75	708.75	1417.5		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1165.5							Fee Schedule																													1417.5							Fee Schedule																																															
MEDARTIS COMPRESSION PLATE A-4645.23	278	RC	C1713	CPT				Both			1575	708.75	708.75	1417.5		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1165.5							Fee Schedule																													1417.5							Fee Schedule																																															
MEDARTIS CORRECTION PLATE A-4750.07	278	RC	C1713	CPT				Both			3195	1437.75	1437.75	2875.5		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	2364.3							Fee Schedule																													2875.5							Fee Schedule																																															
MEDARTIS CORRECTION PLATE A-4750.08	278	RC	C1713	CPT				Both			3195	1437.75	1437.75	2875.5		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	2364.3							Fee Schedule																													2875.5							Fee Schedule																																															
MEDARTIS CORRECTION PLATE A-4750.09	278	RC	C1713	CPT				Both			3195	1437.75	1437.75	2875.5		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	2364.3							Fee Schedule																													2875.5							Fee Schedule																																															
MEDARTIS CORRECTION PLATE A-4750.10	278	RC	C1713	CPT				Both			3195	1437.75	1437.75	2875.5		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	2364.3							Fee Schedule																													2875.5							Fee Schedule																																															
MEDARTIS CORRECTION PLATE A-4750.11	278	RC	C1713	CPT				Both			3573	1607.85	1607.85	3215.7		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	2644.02							Fee Schedule																													3215.7							Fee Schedule																																															
MEDARTIS CORRECTION PLATE A-4750.12	278	RC	C1713	CPT				Both			3573	1607.85	1607.85	3215.7		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	2644.02							Fee Schedule																													3215.7							Fee Schedule																																															
MEDARTIS CORRECTION PLATE A-4750.13	278	RC	C1713	CPT				Both			3573	1607.85	1607.85	3215.7		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	2644.02							Fee Schedule																													3215.7							Fee Schedule																																															
MEDARTIS CORRECTION PLATE A-4750.14	278	RC	C1713	CPT				Both			3573	1607.85	1607.85	3215.7		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	2644.02							Fee Schedule																													3215.7							Fee Schedule																																															
MEDARTIS CORRECTION PLATE A-4750.15	278	RC	C1713	CPT				Both			3573	1607.85	1607.85	3215.7		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	2644.02							Fee Schedule																													3215.7							Fee Schedule																																															
MEDARTIS CORRECTION PLATE A-4750.16	278	RC	C1713	CPT				Both			3573	1607.85	1607.85	3215.7		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	2644.02							Fee Schedule																													3215.7							Fee Schedule																																															
MEDARTIS CORRECTION PLATE A-4750.17	278	RC	C1713	CPT				Both			3573	1607.85	1607.85	3215.7		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	2644.02							Fee Schedule																													3215.7							Fee Schedule																																															
MEDARTIS CORRECTION PLATE A-4750.18	278	RC	C1713	CPT				Both			3573	1607.85	1607.85	3215.7		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	2644.02							Fee Schedule																													3215.7							Fee Schedule																																															
MEDARTIS CORRECTION PLATE A-4750.19	278	RC	C1713	CPT				Both			3573	1607.85	1607.85	3215.7		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	2644.02							Fee Schedule																													3215.7							Fee Schedule																																															
MEDARTIS CORRECTION PLATE A-4750.20	278	RC	C1713	CPT				Both			3573	1607.85	1607.85	3215.7		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	2644.02							Fee Schedule																													3215.7							Fee Schedule																																															
MEDARTIS CORTEX BONE A-5500.05/1	278	RC	C1713	CPT				Both			309	139.05	139.05	278.1		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	228.66							Fee Schedule																													278.1							Fee Schedule																																															
MEDARTIS CORTEX BONE A-5500.05/1	278	RC	C1713	CPT				Both			309	139.05	139.05	278.1		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	228.66							Fee Schedule																													278.1							Fee Schedule																																															
MEDARTIS CORTEX BONE A-5500.06/1	278	RC	C1713	CPT				Both			309	139.05	139.05	278.1		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	228.66							Fee Schedule																													278.1							Fee Schedule																																															
MEDARTIS CORTEX BONE A-5500.06/1	278	RC	C1713	CPT				Both			309	139.05	139.05	278.1		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	228.66							Fee Schedule																													278.1							Fee Schedule																																															
MEDARTIS CORTEX BONE A-5500.07/1	278	RC	C1713	CPT				Both			309	139.05	139.05	278.1		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	228.66							Fee Schedule																													278.1							Fee Schedule																																															
MEDARTIS CORTEX BONE A-5500.08/1	278	RC	C1713	CPT				Both			309	139.05	139.05	278.1		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	228.66							Fee Schedule																													278.1							Fee Schedule																																															
MEDARTIS CORTEX BONE A-5500.09/1	278	RC	C1713	CPT				Both			309	139.05	139.05	278.1		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	228.66							Fee Schedule																													278.1							Fee Schedule																																															
MEDARTIS CORTEX BONE A-5500.10/1	278	RC	C1713	CPT				Both			309	139.05	139.05	278.1		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	228.66							Fee Schedule																													278.1							Fee Schedule																																															
MEDARTIS CORTEX BONE A-5500.11/1	278	RC	C1713	CPT				Both			309	139.05	139.05	278.1		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	228.66							Fee Schedule																													278.1							Fee Schedule																																															
MEDARTIS CORTEX BONE A-5500.12/1	278	RC	C1713	CPT				Both			309	139.05	139.05	278.1		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	228.66							Fee Schedule																													278.1							Fee Schedule																																															
MEDARTIS CORTEX BONE A-5500.13/1	278	RC	C1713	CPT				Both			309	139.05	139.05	278.1		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	228.66							Fee Schedule																													278.1							Fee Schedule																																															
MEDARTIS CORTEX BONE A-5500.14/1	278	RC	C1713	CPT				Both			309	139.05	139.05	278.1		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	228.66							Fee Schedule																													278.1							Fee Schedule																																															
MEDARTIS CORTEX BONE A-5500.15/1	278	RC	C1713	CPT				Both			309	139.05	139.05	278.1		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	228.66							Fee Schedule																													278.1							Fee Schedule																																															
MEDARTIS CORTEX BONE A-5500.16/1	278	RC	C1713	CPT				Both			309	139.05	139.05	278.1		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	228.66							Fee Schedule																													278.1							Fee Schedule																																															
MEDARTIS CORTEX BONE A-5500.17/1	278	RC	C1713	CPT				Both			309	139.05	139.05	278.1		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	228.66							Fee Schedule																													278.1							Fee Schedule																																															
MEDARTIS CORTEX BONE A-5500.18/1	278	RC	C1713	CPT				Both			309	139.05	139.05	278.1		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	228.66							Fee Schedule																													278.1							Fee Schedule																																															
MEDARTIS CORTEX BONE A-5500.19/1	278	RC	C1713	CPT				Both			309	139.05	139.05	278.1		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	228.66							Fee Schedule																													278.1							Fee Schedule																																															
MEDARTIS CORTEX BONE A-5500.20/1	278	RC	C1713	CPT				Both			309	139.05	139.05	278.1		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	228.66							Fee Schedule																													278.1							Fee Schedule																																															
MEDARTIS CORTEX BONE A-5500.21/1	278	RC	C1713	CPT				Both			309	139.05	139.05	278.1		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	228.66							Fee Schedule																													278.1							Fee Schedule																																															
MEDARTIS CORTEX BONE A-5500.22/1	278	RC	C1713	CPT				Both			309	139.05	139.05	278.1		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	228.66							Fee Schedule																													278.1							Fee Schedule																																															
MEDARTIS CORTEX BONE A-5500.23/1	278	RC	C1713	CPT				Both			309	139.05	139.05	278.1		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	228.66							Fee Schedule																													278.1							Fee Schedule																																															
MEDARTIS CORTEX BONE A-5500.24/1	278	RC	C1713	CPT				Both			309	139.05	139.05	278.1		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	228.66							Fee Schedule																													278.1							Fee Schedule																																															
MEDARTIS CORTEX BONE A-5500.26/1	278	RC	C1713	CPT				Both			309	139.05	139.05	278.1		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	228.66							Fee Schedule																													278.1							Fee Schedule																																															
MEDARTIS CORTEX BONE A-5500.28/1	278	RC	C1713	CPT				Both			309	139.05	139.05	278.1		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	228.66							Fee Schedule																													278.1							Fee Schedule																																															
MEDARTIS CORTEX BONE A-5500.30/1	278	RC	C1713	CPT				Both			309	139.05	139.05	278.1		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	228.66							Fee Schedule																													278.1							Fee Schedule																																															
MEDARTIS CORTEX BONE A-5500.32/1	278	RC	C1713	CPT				Both			309	139.05	139.05	278.1		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	228.66							Fee Schedule																													278.1							Fee Schedule																																															
MEDARTIS CORTEX BONE A-5500.34/1	278	RC	C1713	CPT				Both			309	139.05	139.05	278.1		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	228.66							Fee Schedule																													278.1							Fee Schedule																																															
MEDARTIS COUNTERSINK SCREW A-3610	278	RC	C1713	CPT				Both			798	359.1	359.1	718.2		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	590.52							Fee Schedule																													718.2							Fee Schedule																																															
MEDARTIS COUNTERSINKS A-3830	272	RC	C1713	CPT				Both			798	359.1	306.41	718.2	306.41							Fee Schedule		590.52							Fee Schedule																													718.2							Fee Schedule																																															
MEDARTIS DIST. RAD. PLATE A-4750.41	278	RC	C1713	CPT				Both			3948	1776.6	1776.6	3553.2		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	2921.52							Fee Schedule																													3553.2							Fee Schedule																																															
MEDARTIS DIST. RAD. PLATE A-4750.42	278	RC	C1713	CPT				Both			3948	1776.6	1776.6	3553.2		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	2921.52							Fee Schedule																													3553.2							Fee Schedule																																															
MEDARTIS DIST. RAD. PLATE A-4750.43	278	RC	C1713	CPT				Both			4194	1887.3	1887.3	3774.6		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	3103.56							Fee Schedule																													3774.6							Fee Schedule																																															
MEDARTIS DIST. RAD. PLATE A-4750.44	278	RC	C1713	CPT				Both			4194	1887.3	1887.3	3774.6		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	3103.56							Fee Schedule																													3774.6							Fee Schedule																																															
MEDARTIS DRILL A-3832	272	RC						Both			348	156.6	156.6	313.2	226.2							Fee Schedule		257.52							Fee Schedule																													313.2							Fee Schedule																																															
MEDARTIS DRILL A-3834	272	RC						Both			348	156.6	156.6	313.2	226.2							Fee Schedule		257.52							Fee Schedule																													313.2							Fee Schedule																																															
MEDARTIS DRILL A-3837	272	RC						Both			348	156.6	156.6	313.2	226.2							Fee Schedule		257.52							Fee Schedule																													313.2							Fee Schedule																																															
MEDARTIS DRILL BIT A-3230	272	RC						Both			348	156.6	156.6	313.2	226.2							Fee Schedule		257.52							Fee Schedule																													313.2							Fee Schedule																																															
MEDARTIS DRILL BIT A-3410	272	RC						Both			348	156.6	156.6	313.2	226.2							Fee Schedule		257.52							Fee Schedule																													313.2							Fee Schedule																																															
MEDARTIS DRILL BIT A-3411	272	RC						Both			348	156.6	156.6	313.2	226.2							Fee Schedule		257.52							Fee Schedule																													313.2							Fee Schedule																																															
MEDARTIS DRILL BIT A-3420	272	RC						Both			348	156.6	156.6	313.2	226.2							Fee Schedule		257.52							Fee Schedule																													313.2							Fee Schedule																																															
MEDARTIS DRILL BIT A-3421	272	RC						Both			348	156.6	156.6	313.2	226.2							Fee Schedule		257.52							Fee Schedule																													313.2							Fee Schedule																																															
MEDARTIS DRILL BIT A-3430	272	RC						Both			348	156.6	156.6	313.2	226.2							Fee Schedule		257.52							Fee Schedule																													313.2							Fee Schedule																																															
MEDARTIS DRILL BIT A-3431	272	RC						Both			348	156.6	156.6	313.2	226.2							Fee Schedule		257.52							Fee Schedule																													313.2							Fee Schedule																																															
MEDARTIS DRILL BIT A-3434	272	RC						Both			348	156.6	156.6	313.2	226.2							Fee Schedule		257.52							Fee Schedule																													313.2							Fee Schedule																																															
MEDARTIS DRILL BIT A-3510	272	RC						Both			348	156.6	156.6	313.2	226.2							Fee Schedule		257.52							Fee Schedule																													313.2							Fee Schedule																																															
MEDARTIS DRILL BIT A-3511	272	RC						Both			348	156.6	156.6	313.2	226.2							Fee Schedule		257.52							Fee Schedule																													313.2							Fee Schedule																																															
MEDARTIS DRILL BIT A-3520	272	RC						Both			348	156.6	156.6	313.2	226.2							Fee Schedule		257.52							Fee Schedule																													313.2							Fee Schedule																																															
MEDARTIS DRILL BIT A-3521	272	RC						Both			348	156.6	156.6	313.2	226.2							Fee Schedule		257.52							Fee Schedule																													313.2							Fee Schedule																																															
MEDARTIS DRILL BIT A-3530	272	RC						Both			348	156.6	156.6	313.2	226.2							Fee Schedule		257.52							Fee Schedule																													313.2							Fee Schedule																																															
MEDARTIS DRILL BIT A-3531	272	RC						Both			348	156.6	156.6	313.2	226.2							Fee Schedule		257.52							Fee Schedule																													313.2							Fee Schedule																																															
MEDARTIS DRILL BIT A-3710	272	RC						Both			311.85	140.33	140.33	280.67	202.7							Fee Schedule		230.77							Fee Schedule																													280.67							Fee Schedule																																															
MEDARTIS DRILL BIT A-3711	272	RC						Both			348	156.6	156.6	313.2	226.2							Fee Schedule		257.52							Fee Schedule																													313.2							Fee Schedule																																															
MEDARTIS DRILL BIT A-3713	272	RC						Both			348	156.6	156.6	313.2	226.2							Fee Schedule		257.52							Fee Schedule																													313.2							Fee Schedule																																															
MEDARTIS DRILL BIT A-3720	272	RC						Both			311.85	140.33	140.33	280.67	202.7							Fee Schedule		230.77							Fee Schedule																													280.67							Fee Schedule																																															
MEDARTIS DRILL BIT A-3721	272	RC						Both			348	156.6	156.6	313.2	226.2							Fee Schedule		257.52							Fee Schedule																													313.2							Fee Schedule																																															
MEDARTIS DRILL BIT A-3723	272	RC						Both			348	156.6	156.6	313.2	226.2							Fee Schedule		257.52							Fee Schedule																													313.2							Fee Schedule																																															
MEDARTIS DRILL BIT A-3730	272	RC						Both			348	156.6	156.6	313.2	226.2							Fee Schedule		257.52							Fee Schedule																													313.2							Fee Schedule																																															
MEDARTIS DRILL BIT A-3731	270	RC						Both			348	156.6	156.6	313.2	226.2							Fee Schedule		257.52							Fee Schedule																													313.2							Fee Schedule																																															
MEDARTIS DRILL BIT A-3733	272	RC	C1713	CPT				Both			348	156.6	156.6	313.2	306.41							Fee Schedule		257.52							Fee Schedule																													313.2							Fee Schedule																																															
"MEDARTIS DRILL GUIDE LCK, LEFT A-2723.01"	272	RC						Both			1158	521.1	521.1	1042.2	752.7							Fee Schedule		856.92							Fee Schedule																													1042.2							Fee Schedule																																															
MEDARTIS DRILL GUIDE RIGHT A-2723.02	272	RC						Both			1158	521.1	521.1	1042.2	752.7							Fee Schedule		856.92							Fee Schedule																													1042.2							Fee Schedule																																															
MEDARTIS FRACTURE PLATE A-4750.31	278	RC	C1713	CPT				Both			4356	1960.2	1960.2	3920.4		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	3223.44							Fee Schedule																													3920.4							Fee Schedule																																															
MEDARTIS FRACTURE PLATE A-4750.32	278	RC	C1713	CPT				Both			4356	1960.2	1960.2	3920.4		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	3223.44							Fee Schedule																													3920.4							Fee Schedule																																															
MEDARTIS K-WIRE 1.6MM A-5040.40/1	278	RC						Both			313.95	141.28	141.28	282.56		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	232.32							Fee Schedule																													282.56							Fee Schedule																																															
MEDARTIS K-WIRE 1.6MM A-5040.41	278	RC	C1713	CPT				Both			87	39.15	39.15	78.3		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	64.38							Fee Schedule																													78.3							Fee Schedule																																															
MEDARTIS K-WIRE 1.6MM A-5040.41/1	270	RC						Both			87	39.15	39.15	78.3	56.55							Fee Schedule		64.38							Fee Schedule																													78.3							Fee Schedule																																															
MEDARTIS K-WIRE A-5040.21/1	278	RC						Both			87	39.15	39.15	78.3		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	64.38							Fee Schedule																													78.3							Fee Schedule																																															
MEDARTIS K-WIRE A-5040.21/1	278	RC						Both			87	39.15	39.15	78.3		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	64.38							Fee Schedule																													78.3							Fee Schedule																																															
MEDARTIS K-WIRE A-5042.21/1	278	RC	C1713	CPT				Both			87	39.15	39.15	78.3		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	64.38							Fee Schedule																													78.3							Fee Schedule																																															
MEDARTIS K-WIRE A-5042.41/1	278	RC						Both			87	39.15	39.15	78.3		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	64.38							Fee Schedule																													78.3							Fee Schedule																																															
MEDARTIS K-WIRE DISPENSER A-6010.16	272	RC						Both			304.5	137.03	137.03	274.05	197.93							Fee Schedule		225.33							Fee Schedule																													274.05							Fee Schedule																																															
MEDARTIS K-WIRE TROCAR A-5040.00/1	278	RC	C1769	CPT				Both			87	39.15	39.15	78.3		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	64.38							Fee Schedule																													78.3							Fee Schedule																																															
MEDARTIS K-WIRE TROCAR A-5040.10/1	278	RC	C1769	CPT				Both			87	39.15	39.15	78.3		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	64.38							Fee Schedule																													78.3							Fee Schedule																																															
MEDARTIS LOCK PLATE A-4750.25	278	RC	C1713	CPT				Both			4704	2116.8	2116.8	4233.6		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	3480.96							Fee Schedule																													4233.6							Fee Schedule																																															
MEDARTIS LOCK PLATE A-4750.26	278	RC	C1713	CPT				Both			4704	2116.8	2116.8	4233.6		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	3480.96							Fee Schedule																													4233.6							Fee Schedule																																															
MEDARTIS LOCK PLATE A-4750.54	278	RC	C1713	CPT				Both			2640	1188	1188	2376		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1953.6							Fee Schedule																													2376							Fee Schedule																																															
MEDARTIS LOCK PLATE A-4750.55	278	RC	C1713	CPT				Both			2640	1188	1188	2376		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1953.6							Fee Schedule																													2376							Fee Schedule																																															
MEDARTIS LOCK PLATE A-4750.56	278	RC	C1713	CPT				Both			2640	1188	1188	2376		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1953.6							Fee Schedule																													2376							Fee Schedule																																															
MEDARTIS LOCK PLATE A-4750.57	278	RC	C1713	CPT				Both			2640	1188	1188	2376		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1953.6							Fee Schedule																													2376							Fee Schedule																																															
MEDARTIS LOCK PLATE A-4750.58	278	RC	C1713	CPT				Both			2640	1188	1188	2376		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1953.6							Fee Schedule																													2376							Fee Schedule																																															
MEDARTIS LOCKING EXPRESS A-5755.14/1	278	RC	C1713	CPT				Both			396	178.2	178.2	356.4		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	293.04							Fee Schedule																													356.4							Fee Schedule																																															
MEDARTIS LOCKING EXPRESS A-5755.16/1	278	RC	C1713	CPT				Both			396	178.2	178.2	356.4		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	293.04							Fee Schedule																													356.4							Fee Schedule																																															
MEDARTIS LOCKING EXPRESS A-5755.18/1	278	RC	C1713	CPT				Both			396	178.2	178.2	356.4		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	293.04							Fee Schedule																													356.4							Fee Schedule																																															
MEDARTIS LOCKING EXPRESS A-5755.20/1	278	RC	C1713	CPT				Both			396	178.2	178.2	356.4		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	293.04							Fee Schedule																													356.4							Fee Schedule																																															
MEDARTIS LOCKING EXPRESS A-5755.22/1	278	RC	C1713	CPT				Both			396	178.2	178.2	356.4		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	293.04							Fee Schedule																													356.4							Fee Schedule																																															
MEDARTIS LOCKING EXPRESS A-5755.24/1	278	RC	C1713	CPT				Both			396	178.2	178.2	356.4		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	293.04							Fee Schedule																													356.4							Fee Schedule																																															
MEDARTIS LOCKING PLATE A-4350.62	278	RC	C1713	CPT				Both			2364	1063.8	1063.8	2127.6		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1749.36							Fee Schedule																													2127.6							Fee Schedule																																															
MEDARTIS LOCKING PLATE A-4350.66	278	RC	C1713	CPT				Both			2412	1085.4	1085.4	2170.8		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1784.88							Fee Schedule																													2170.8							Fee Schedule																																															
MEDARTIS LOCKING PLATE A-4650.03	278	RC	C1713	CPT				Both			1692	761.4	761.4	1522.8		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1252.08							Fee Schedule																													1522.8							Fee Schedule																																															
MEDARTIS LOCKING PLATE A-4650.10	278	RC	C1713	CPT				Both			1164	523.8	523.8	1047.6		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	861.36							Fee Schedule																													1047.6							Fee Schedule																																															
MEDARTIS LOCKING PLATE A-4650.11	278	RC	C1713	CPT				Both			1827	822.15	822.15	1644.3		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1351.98							Fee Schedule																													1644.3							Fee Schedule																																															
MEDARTIS LOCKING PLATE A-4650.13	278	RC	C1713	CPT				Both			1797	808.65	808.65	1617.3		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1329.78							Fee Schedule																													1617.3							Fee Schedule																																															
MEDARTIS LOCKING PLATE A-4650.20	278	RC	C1713	CPT				Both			1728	777.6	777.6	1555.2		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1278.72							Fee Schedule																													1555.2							Fee Schedule																																															
MEDARTIS LOCKING PLATE A-4650.21	278	RC	C1713	CPT				Both			1728	777.6	777.6	1555.2		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1278.72							Fee Schedule																													1555.2							Fee Schedule																																															
MEDARTIS LOCKING PLATE A-4650.51	278	RC	C1713	CPT				Both			2031	913.95	913.95	1827.9		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1502.94							Fee Schedule																													1827.9							Fee Schedule																																															
MEDARTIS LOCKING PLATE A-4650.56	278	RC	C1713	CPT				Both			2097	943.65	943.65	1887.3		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1551.78							Fee Schedule																													1887.3							Fee Schedule																																															
MEDARTIS LOCKING PLATE A-4650.58	278	RC	C1713	CPT				Both			2211	994.95	994.95	1989.9		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1636.14							Fee Schedule																													1989.9							Fee Schedule																																															
MEDARTIS LOCKING PLATE A-4650.59	278	RC	C1713	CPT				Both			2211	994.95	994.95	1989.9		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1636.14							Fee Schedule																													1989.9							Fee Schedule																																															
MEDARTIS LOCKING PLATE A-4650.62	278	RC	C1713	CPT				Both			2211	994.95	994.95	1989.9		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1636.14							Fee Schedule																													1989.9							Fee Schedule																																															
MEDARTIS LOCKING PLATE A-4650.67	278	RC	C1713	CPT				Both			2307	1038.15	1038.15	2076.3		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1707.18							Fee Schedule																													2076.3							Fee Schedule																																															
MEDARTIS LOCKING PLATE A-4655.01	278	RC	C1713	CPT				Both			2211	994.95	994.95	1989.9		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1636.14							Fee Schedule																													1989.9							Fee Schedule																																															
MEDARTIS LOCKING PLATE A-4655.02	278	RC	C1713	CPT				Both			2328	1047.6	1047.6	2095.2		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1722.72							Fee Schedule																													2095.2							Fee Schedule																																															
MEDARTIS LOCKING PLATE A-4655.03	278	RC	C1713	CPT				Both			2439	1097.55	1097.55	2195.1		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1804.86							Fee Schedule																													2195.1							Fee Schedule																																															
MEDARTIS LOCKING PLATE A-4655.08	278	RC	C1713	CPT				Both			2685	1208.25	1208.25	2416.5		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1986.9							Fee Schedule																													2416.5							Fee Schedule																																															
MEDARTIS LOCKING PLATE A-4655.10	278	RC	C1713	CPT				Both			2712	1220.4	1220.4	2440.8		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	2006.88							Fee Schedule																													2440.8							Fee Schedule																																															
MEDARTIS LOCKING PLATE A-4655.11	278	RC	C1713	CPT				Both			2814	1266.3	1266.3	2532.6		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	2082.36							Fee Schedule																													2532.6							Fee Schedule																																															
MEDARTIS LOCKING PLATE A-4655.12	278	RC	C1713	CPT				Both			3384	1522.8	1522.8	3045.6		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	2504.16							Fee Schedule																													3045.6							Fee Schedule																																															
MEDARTIS LOCKING PLATE A-4655.13	278	RC	C1713	CPT				Both			3567	1605.15	1605.15	3210.3		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	2639.58							Fee Schedule																													3210.3							Fee Schedule																																															
MEDARTIS LOCKING PLATE A-4655.16	278	RC	C1713	CPT				Both			2865	1289.25	1289.25	2578.5		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	2120.1							Fee Schedule																													2578.5							Fee Schedule																																															
MEDARTIS LOCKING PLATE A-4655.20	278	RC	C1713	CPT				Both			2712	1220.4	1220.4	2440.8		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	2006.88							Fee Schedule																													2440.8							Fee Schedule																																															
MEDARTIS LOCKING PLATE A-4655.21	278	RC	C1713	CPT				Both			2712	1220.4	1220.4	2440.8		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	2006.88							Fee Schedule																													2440.8							Fee Schedule																																															
MEDARTIS LOCKING PLATE A-4655.22	278	RC	C1713	CPT				Both			2865	1289.25	1289.25	2578.5		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	2120.1							Fee Schedule																													2578.5							Fee Schedule																																															
MEDARTIS LOCKING PLATE A-4655.23	278	RC	C1713	CPT				Both			2865	1289.25	1289.25	2578.5		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	2120.1							Fee Schedule																													2578.5							Fee Schedule																																															
MEDARTIS LOCKING PLATE A-4655.51	278	RC	C1713	CPT				Both			2712	1220.4	1220.4	2440.8		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	2006.88							Fee Schedule																													2440.8							Fee Schedule																																															
MEDARTIS LOCKING PLATE A-4655.56	278	RC	C1713	CPT				Both			2799	1259.55	1259.55	2519.1		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	2071.26							Fee Schedule																													2519.1							Fee Schedule																																															
MEDARTIS LOCKING PLATE A-4655.62	278	RC	C1713	CPT				Both			2937	1321.65	1321.65	2643.3		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	2173.38							Fee Schedule																													2643.3							Fee Schedule																																															
MEDARTIS LOCKING PLATE A-4655.66	278	RC	C1713	CPT				Both			3066	1379.7	1379.7	2759.4		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	2268.84							Fee Schedule																													2759.4							Fee Schedule																																															
MEDARTIS LOCKING PLATE A-4655.67	278	RC	C1713	CPT				Both			3828	1722.6	1722.6	3445.2		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	2832.72							Fee Schedule																													3445.2							Fee Schedule																																															
MEDARTIS LOCKING PLATE A-4655.68	278	RC	C1713	CPT				Both			3999	1799.55	1799.55	3599.1		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	2959.26							Fee Schedule																													3599.1							Fee Schedule																																															
MEDARTIS LOCKING PLATE A-4655.69	278	RC	C1713	CPT				Both			4173	1877.85	1877.85	3755.7		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	3088.02							Fee Schedule																													3755.7							Fee Schedule																																															
MEDARTIS LOCKING PLATE A-4750.101	278	RC	C1713	CPT				Both			3945	1775.25	1775.25	3550.5		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	2919.3							Fee Schedule																													3550.5							Fee Schedule																																															
MEDARTIS LOCKING PLATE A-4750.102	278	RC	C1713	CPT				Both			3945	1775.25	1775.25	3550.5		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	2919.3							Fee Schedule																													3550.5							Fee Schedule																																															
MEDARTIS LOCKING PLATE A-4750.104	278	RC	C1713	CPT				Both			4446	2000.7	2000.7	4001.4		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	3290.04							Fee Schedule																													4001.4							Fee Schedule																																															
MEDARTIS LOCKING PLATE A-4750.72	278	RC	C1713	CPT				Both			1815	816.75	816.75	1633.5		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1343.1							Fee Schedule																													1633.5							Fee Schedule																																															
MEDARTIS LOCKING PLATE A-4750.73	278	RC	C1713	CPT				Both			1998	899.1	899.1	1798.2		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1478.52							Fee Schedule																													1798.2							Fee Schedule																																															
MEDARTIS LOCKING PLATE A-4750.74	278	RC	C1713	CPT				Both			1998	899.1	899.1	1798.2		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1478.52							Fee Schedule																													1798.2							Fee Schedule																																															
MEDARTIS LOCKING PLATE A-4750.76	278	RC	C1713	CPT				Both			5877	2644.65	2644.65	5289.3		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	4348.98							Fee Schedule																													5289.3							Fee Schedule																																															
MEDARTIS LOCKING PLATE A-4750.91	278	RC	C1713	CPT				Both			2937	1321.65	1321.65	2643.3		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	2173.38							Fee Schedule																													2643.3							Fee Schedule																																															
MEDARTIS LOCKING PLATE A-4750.92	278	RC	C1713	CPT				Both			3093	1391.85	1391.85	2783.7		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	2288.82							Fee Schedule																													2783.7							Fee Schedule																																															
MEDARTIS LOCKING PLATE A-4750.95	278	RC	C1713	CPT				Both			5208	2343.6	2343.6	4687.2		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	3853.92							Fee Schedule																													4687.2							Fee Schedule																																															
MEDARTIS LOCKING SCREW 10MM A-5750.10/1	278	RC	C1713	CPT				Both			507	228.15	228.15	456.3		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	375.18							Fee Schedule																													456.3							Fee Schedule																																															
MEDARTIS LOCKING SCREW 12MM A-5750.12/1	278	RC	C1713	CPT				Both			507	228.15	228.15	456.3		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	375.18							Fee Schedule																													456.3							Fee Schedule																																															
MEDARTIS LOCKING SCREW 14MM A-5750.14/1	278	RC	C1713	CPT				Both			507	228.15	228.15	456.3		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	375.18							Fee Schedule																													456.3							Fee Schedule																																															
MEDARTIS LOCKING SCREW 16MM A-5750.16/1	278	RC	C1713	CPT				Both			507	228.15	228.15	456.3		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	375.18							Fee Schedule																													456.3							Fee Schedule																																															
MEDARTIS LOCKING SCREW 18MM A-5750.18/1	278	RC	C1713	CPT				Both			507	228.15	228.15	456.3		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	375.18							Fee Schedule																													456.3							Fee Schedule																																															
MEDARTIS LOCKING SCREW 20MM A-5750.20/1	278	RC	C1713	CPT				Both			507	228.15	228.15	456.3		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	375.18							Fee Schedule																													456.3							Fee Schedule																																															
MEDARTIS LOCKING SCREW 22MM A-5750.22/1	278	RC	C1713	CPT				Both			507	228.15	228.15	456.3		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	375.18							Fee Schedule																													456.3							Fee Schedule																																															
MEDARTIS LOCKING SCREW 24MM #A-5750.24/1	278	RC	C1713	CPT				Both			507	228.15	228.15	456.3		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	375.18							Fee Schedule																													456.3							Fee Schedule																																															
MEDARTIS LOCKING SCREW 24MM A-5750.24/1	278	RC	C1713	CPT				Both			507	228.15	228.15	456.3		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	375.18							Fee Schedule																													456.3							Fee Schedule																																															
MEDARTIS LOCKING SCREW 26MM A-5750.26/1	278	RC	C1713	CPT				Both			507	228.15	228.15	456.3		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	375.18							Fee Schedule																													456.3							Fee Schedule																																															
MEDARTIS LOCKING SCREW 28MM A-5750.28/1	278	RC	C1713	CPT				Both			507	228.15	228.15	456.3		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	375.18							Fee Schedule																													456.3							Fee Schedule																																															
MEDARTIS LOCKING SCREW 30MM A-5750.30/1	278	RC	C1713	CPT				Both			507	228.15	228.15	456.3		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	375.18							Fee Schedule																													456.3							Fee Schedule																																															
MEDARTIS LOCKING SCREW 32MM A-5750.32/1	278	RC	C1713	CPT				Both			507	228.15	228.15	456.3		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	375.18							Fee Schedule																													456.3							Fee Schedule																																															
MEDARTIS LOCKING SCREW 34MM A-5750.34/1	278	RC	C1713	CPT				Both			507	228.15	228.15	456.3		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	375.18							Fee Schedule																													456.3							Fee Schedule																																															
MEDARTIS LOCKING SCREW 8MM A-5750.08/1	278	RC	C1713	CPT				Both			507	228.15	228.15	456.3		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	375.18							Fee Schedule																													456.3							Fee Schedule																																															
MEDARTIS LOCKING SCREW A-5250.07/1	278	RC	C1713	CPT				Both			507	228.15	228.15	456.3		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	375.18							Fee Schedule																													456.3							Fee Schedule																																															
MEDARTIS LOCKING SCREW A-5250.08/1	278	RC	C1713	CPT				Both			507	228.15	228.15	456.3		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	375.18							Fee Schedule																													456.3							Fee Schedule																																															
MEDARTIS LOCKING SCREW A-5250.09/1	278	RC	C1713	CPT				Both			507	228.15	228.15	456.3		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	375.18							Fee Schedule																													456.3							Fee Schedule																																															
MEDARTIS LOCKING SCREW A-5250.10/1	278	RC	C1713	CPT				Both			507	228.15	228.15	456.3		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	375.18							Fee Schedule																													456.3							Fee Schedule																																															
MEDARTIS LOCKING SCREW A-5250.12/1	278	RC	C1713	CPT				Both			507	228.15	228.15	456.3		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	375.18							Fee Schedule																													456.3							Fee Schedule																																															
MEDARTIS LOCKING SCREW A-5250.13/1	278	RC	C1713	CPT				Both			507	228.15	228.15	456.3		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	375.18							Fee Schedule																													456.3							Fee Schedule																																															
MEDARTIS LOCKING SCREW A-5450.06/1	278	RC	C1713	CPT				Both			507	228.15	228.15	456.3		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	375.18							Fee Schedule																													456.3							Fee Schedule																																															
MEDARTIS LOCKING SCREW A-5450.07/1	278	RC	C1713	CPT				Both			507	228.15	228.15	456.3		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	375.18							Fee Schedule																													456.3							Fee Schedule																																															
MEDARTIS LOCKING SCREW A-5450.08/1	278	RC	C1713	CPT				Both			507	228.15	228.15	456.3		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	375.18							Fee Schedule																													456.3							Fee Schedule																																															
MEDARTIS LOCKING SCREW A-5450.09/1	278	RC	C1713	CPT				Both			507	228.15	228.15	456.3		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	375.18							Fee Schedule																													456.3							Fee Schedule																																															
MEDARTIS LOCKING SCREW A-5450.10/1	278	RC	C1713	CPT				Both			507	228.15	228.15	456.3		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	375.18							Fee Schedule																													456.3							Fee Schedule																																															
MEDARTIS LOCKING SCREW A-5450.11/1	278	RC	C1713	CPT				Both			507	228.15	228.15	456.3		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	375.18							Fee Schedule																													456.3							Fee Schedule																																															
MEDARTIS LOCKING SCREW A-5450.12/1	278	RC	C1713	CPT				Both			507	228.15	228.15	456.3		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	375.18							Fee Schedule																													456.3							Fee Schedule																																															
MEDARTIS LOCKING SCREW A-5450.13/1	278	RC	C1713	CPT				Both			507	228.15	228.15	456.3		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	375.18							Fee Schedule																													456.3							Fee Schedule																																															
MEDARTIS LOCKING SCREW A-5450.14/1	278	RC	C1713	CPT				Both			507	228.15	228.15	456.3		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	375.18							Fee Schedule																													456.3							Fee Schedule																																															
MEDARTIS LOCKING SCREW A-5450.16/1	278	RC	C1713	CPT				Both			507	228.15	228.15	456.3		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	375.18							Fee Schedule																													456.3							Fee Schedule																																															
MEDARTIS LOCKING SCREW A-5450.18/1	278	RC	C1713	CPT				Both			507	228.15	228.15	456.3		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	375.18							Fee Schedule																													456.3							Fee Schedule																																															
MEDARTIS LOCKING SCREW A-5450.20/1	278	RC	C1713	CPT				Both			507	228.15	228.15	456.3		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	375.18							Fee Schedule																													456.3							Fee Schedule																																															
MEDARTIS LOCKING SCREW A-5450.22/1	278	RC	C1713	CPT				Both			507	228.15	228.15	456.3		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	375.18							Fee Schedule																													456.3							Fee Schedule																																															
MEDARTIS LOCKING SCREW A-5450.24/1	278	RC	C1713	CPT				Both			507	228.15	228.15	456.3		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	375.18							Fee Schedule																													456.3							Fee Schedule																																															
MEDARTIS LOCKING SCREW A-5450.26/1	278	RC	C1713	CPT				Both			507	228.15	228.15	456.3		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	375.18							Fee Schedule																													456.3							Fee Schedule																																															
MEDARTIS LOCKING SCREW A-5450.28/1	278	RC	C1713	CPT				Both			507	228.15	228.15	456.3		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	375.18							Fee Schedule																													456.3							Fee Schedule																																															
MEDARTIS LOCKING SCREW A-5450.30/1	278	RC	C1713	CPT				Both			507	228.15	228.15	456.3		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	375.18							Fee Schedule																													456.3							Fee Schedule																																															
MEDARTIS LOCKING SCREW A-5750.26/1	278	RC	C1713	CPT				Both			507	228.15	228.15	456.3		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	375.18							Fee Schedule																													456.3							Fee Schedule																																															
MEDARTIS MEDIAL FUSION PLATE A-4860.31	278	RC	C1713	CPT				Both			12705	5717.25	5717.25	11434.5		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	9401.7							Fee Schedule																													11434.5							Fee Schedule																																															
MEDARTIS NON LOCKING SCREW A-5700.08/1	278	RC	C1713	CPT				Both			309	139.05	139.05	278.1		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	228.66							Fee Schedule																													278.1							Fee Schedule																																															
MEDARTIS NON LOCKING SCREW A-5700.10/1	278	RC	C1713	CPT				Both			309	139.05	139.05	278.1		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	228.66							Fee Schedule																													278.1							Fee Schedule																																															
MEDARTIS NON LOCKING SCREW A-5700.12/1	278	RC	C1713	CPT				Both			309	139.05	139.05	278.1		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	228.66							Fee Schedule																													278.1							Fee Schedule																																															
MEDARTIS NON LOCKING SCREW A-5700.14/1	278	RC	C1713	CPT				Both			309	139.05	139.05	278.1		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	228.66							Fee Schedule																													278.1							Fee Schedule																																															
MEDARTIS NON LOCKING SCREW A-5700.16/1	278	RC	C1713	CPT				Both			309	139.05	139.05	278.1		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	228.66							Fee Schedule																													278.1							Fee Schedule																																															
MEDARTIS NON LOCKING SCREW A-5700.18/1	278	RC	C1713	CPT				Both			309	139.05	139.05	278.1		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	228.66							Fee Schedule																													278.1							Fee Schedule																																															
MEDARTIS NON LOCKING SCREW A-5700.20/1	278	RC	C1713	CPT				Both			309	139.05	139.05	278.1		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	228.66							Fee Schedule																													278.1							Fee Schedule																																															
MEDARTIS NON LOCKING SCREW A-5700.22/1	278	RC	C1713	CPT				Both			309	139.05	139.05	278.1		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	228.66							Fee Schedule																													278.1							Fee Schedule																																															
MEDARTIS NON LOCKING SCREW A-5700.24/1	278	RC	C1713	CPT				Both			309	139.05	139.05	278.1		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	228.66							Fee Schedule																													278.1							Fee Schedule																																															
MEDARTIS NON LOCKING SCREW A-5700.26/1	278	RC	C1713	CPT				Both			309	139.05	139.05	278.1		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	228.66							Fee Schedule																													278.1							Fee Schedule																																															
MEDARTIS NON LOCKING SCREW A-5700.28/1	278	RC	C1713	CPT				Both			309	139.05	139.05	278.1		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	228.66							Fee Schedule																													278.1							Fee Schedule																																															
MEDARTIS NON LOCKING SCREW A-5700.30/1	278	RC	C1713	CPT				Both			309	139.05	139.05	278.1		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	228.66							Fee Schedule																													278.1							Fee Schedule																																															
MEDARTIS NON LOCKING SCREW A-5700.32/1	278	RC	C1713	CPT				Both			309	139.05	139.05	278.1		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	228.66							Fee Schedule																													278.1							Fee Schedule																																															
MEDARTIS NON LOCKING SCREW A-5700.34/1	278	RC	C1713	CPT				Both			309	139.05	139.05	278.1		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	228.66							Fee Schedule																													278.1							Fee Schedule																																															
MEDARTIS OLECRANON PLATE A-4856.10	278	RC	C1713	CPT				Both			4002	1800.9	1800.9	3601.8		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	2961.48							Fee Schedule																													3601.8							Fee Schedule																																															
MEDARTIS OLECRANON PLATE A-4856.11	278	RC	C1713	CPT				Both			4002	1800.9	1800.9	3601.8		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	2961.48							Fee Schedule																													3601.8							Fee Schedule																																															
MEDARTIS OLECRANON PLATE A-4856.13	278	RC	C1713	CPT				Both			4068	1830.6	1830.6	3661.2		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	3010.32							Fee Schedule																													3661.2							Fee Schedule																																															
MEDARTIS OLECRANON PLATE A-4856.14	278	RC	C1713	CPT				Both			4068	1830.6	1830.6	3661.2		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	3010.32							Fee Schedule																													3661.2							Fee Schedule																																															
MEDARTIS OLECRANON PLATE A-4856.15	278	RC	C1713	CPT				Both			3993	1796.85	1796.85	3593.7		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	2954.82							Fee Schedule																													3593.7							Fee Schedule																																															
MEDARTIS PLATE A-4300.51	278	RC	C1713	CPT				Both			1137	511.65	511.65	1023.3		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	841.38							Fee Schedule																													1023.3							Fee Schedule																																															
MEDARTIS PLATE A-4856.01	278	RC	C1713	CPT				Both			3885	1748.25	1748.25	3496.5		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	2874.9							Fee Schedule																													3496.5							Fee Schedule																																															
MEDARTIS PLATE LEFT #A-4750.105	278	RC	C1713	CPT				Both			3945	1775.25	1775.25	3550.5		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	2919.3							Fee Schedule																													3550.5							Fee Schedule																																															
MEDARTIS RADIUS PLATE A-4750.50	278	RC	C1713	CPT				Both			2640	1188	1188	2376		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1953.6							Fee Schedule																													2376							Fee Schedule																																															
MEDARTIS RADIUS PLATE A-4750.51	278	RC	C1713	CPT				Both			2640	1188	1188	2376		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1953.6							Fee Schedule																													2376							Fee Schedule																																															
MEDARTIS RADIUS PLATE A-4750.52	278	RC	C1713	CPT				Both			2640	1188	1188	2376		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1953.6							Fee Schedule																													2376							Fee Schedule																																															
MEDARTIS RADIUS PLATE A-4750.53	278	RC	C1713	CPT				Both			2640	1188	1188	2376		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1953.6							Fee Schedule																													2376							Fee Schedule																																															
MEDARTIS SCREW 4.0X32MM #A-5936.32/1	278	RC	C1713	CPT				Both			870	391.5	391.5	783		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	643.8							Fee Schedule																													783							Fee Schedule																																															
MEDARTIS SCREW A-5800.10/1	278	RC	C1713	CPT				Both			309	139.05	139.05	278.1		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	228.66							Fee Schedule																													278.1							Fee Schedule																																															
MEDARTIS SCREW A-5800.14/1	278	RC	C1713	CPT				Both			309	139.05	139.05	278.1		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	228.66							Fee Schedule																													278.1							Fee Schedule																																															
MEDARTIS SCREW A-5800.16/1	278	RC	C1713	CPT				Both			309	139.05	139.05	278.1		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	228.66							Fee Schedule																													278.1							Fee Schedule																																															
MEDARTIS SCREW A-5800.18	278	RC	C1713	CPT				Both			309	139.05	139.05	278.1		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	228.66							Fee Schedule																													278.1							Fee Schedule																																															
MEDARTIS SCREW A-5800.20	278	RC	C1713	CPT				Both			309	139.05	139.05	278.1		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	228.66							Fee Schedule																													278.1							Fee Schedule																																															
MEDARTIS SCREW A-5800.28	278	RC	C1713	CPT				Both			309	139.05	139.05	278.1		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	228.66							Fee Schedule																													278.1							Fee Schedule																																															
MEDARTIS SCREW A-5830.45	278	RC	C1713	CPT				Both			303	136.35	136.35	272.7		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	224.22							Fee Schedule																													272.7							Fee Schedule																																															
MEDARTIS SCREW A-5830.50/1	278	RC	C1713	CPT				Both			303	136.35	136.35	272.7		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	224.22							Fee Schedule																													272.7							Fee Schedule																																															
MEDARTIS SCREW A-5830.55	278	RC	C1713	CPT				Both			303	136.35	136.35	272.7		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	224.22							Fee Schedule																													272.7							Fee Schedule																																															
MEDARTIS SCREW A-5850.08/1	278	RC	C1713	CPT				Both			507	228.15	228.15	456.3		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	375.18							Fee Schedule																													456.3							Fee Schedule																																															
MEDARTIS SCREW A-5850.10/1	278	RC	C1713	CPT				Both			507	228.15	228.15	456.3		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	375.18							Fee Schedule																													456.3							Fee Schedule																																															
MEDARTIS SCREW A-5850.12/1	278	RC	C1713	CPT				Both			507	228.15	228.15	456.3		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	375.18							Fee Schedule																													456.3							Fee Schedule																																															
MEDARTIS SCREW A-5850.14/1	278	RC	C1713	CPT				Both			507	228.15	228.15	456.3		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	375.18							Fee Schedule																													456.3							Fee Schedule																																															
MEDARTIS SCREW A-5850.16/1	278	RC	C1713	CPT				Both			507	228.15	228.15	456.3		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	375.18							Fee Schedule																													456.3							Fee Schedule																																															
MEDARTIS SCREW A-5850.40/1	278	RC	C1713	CPT				Both			507	228.15	228.15	456.3		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	375.18							Fee Schedule																													456.3							Fee Schedule																																															
MEDARTIS SCREW A-5850.50/1	278	RC	C1713	CPT				Both			507	228.15	228.15	456.3		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	375.18							Fee Schedule																													456.3							Fee Schedule																																															
MEDARTIS SCREWDRIVER BLADE A-2013	270	RC						Both			624	280.8	280.8	561.6	405.6							Fee Schedule		461.76							Fee Schedule																													561.6							Fee Schedule																																															
MEDARTIS SPEED TIP SCREW A-5210.10	278	RC	C1713	CPT				Both			369	166.05	166.05	332.1		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	273.06							Fee Schedule																													332.1							Fee Schedule																																															
MEDARTIS SPEED TIP SCREW A-5210.12	278	RC	C1713	CPT				Both			369	166.05	166.05	332.1		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	273.06							Fee Schedule																													332.1							Fee Schedule																																															
MEDARTIS SPEED TIP SCREW A-5210.14	278	RC	C1713	CPT				Both			369	166.05	166.05	332.1		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	273.06							Fee Schedule																													332.1							Fee Schedule																																															
MEDARTIS TRILOK PLATE 2/5 HOL #A-4750.91	278	RC	C1713	CPT				Both			2937	1321.65	1321.65	2643.3		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	2173.38							Fee Schedule																													2643.3							Fee Schedule																																															
MEDARTIS WATERSHED PLATE A-4750.63	278	RC	C1713	CPT				Both			4065	1829.25	1829.25	3658.5		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	3008.1							Fee Schedule																													3658.5							Fee Schedule																																															
MEDARTIS WATERSHED PLATE A-4750.64	278	RC	C1713	CPT				Both			4065	1829.25	1829.25	3658.5		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	3008.1							Fee Schedule																													3658.5							Fee Schedule																																															
MEDARTIS WATERSHED PLATE A-4750.65	278	RC	C1713	CPT				Both			1181.25	531.56	531.56	1063.13		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	874.13							Fee Schedule																													1063.13							Fee Schedule																																															
MEDARTIS WATERSHED PLATE LEFT A-4750.61	278	RC	C1713	CPT				Both			3573	1607.85	1607.85	3215.7		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	2644.02							Fee Schedule																													3215.7							Fee Schedule																																															
MEDARTIS WATERSHED PLATE RIGHT A-4750.62	278	RC	C1713	CPT				Both			3573	1607.85	1607.85	3215.7		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	2644.02							Fee Schedule																													3215.7							Fee Schedule																																															
SOFT TISSUE PROCEDURES WITHOUT CC/MCC					502	DRG		Inpatient			32224.41	14500.98	14500.98	14500.98							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period	
MEDICAL SCREENING	451	RC	99281	CPT				Outpatient			199.5	89.78	33.83	352	330							Case Rate		352							Fee Schedule											33.83							Fee Schedule											179.55							Fee Schedule																																															
MEDICOPASTE BANDAGE	271	RC						Both			12.6	5.67	5.67	11.34	8.19							Fee Schedule		9.32							Fee Schedule																													11.34							Fee Schedule																																															
MEDIHONEY CALC. ALG. DSG. 2X2 #31022	272	RC	A6196	CPT				Both			12	5.4	5.4	10.8	6.62							Fee Schedule		8.88							Fee Schedule		10.8							Fee Schedule		8.28							Fee Schedule											10.8							Fee Schedule																																															
MEDIHONEY CALC. ALG. DSG. 4X5 #31045	272	RC	A6197	CPT				Both			27	12.15	9.76	24.3	14.8							Fee Schedule		19.98							Fee Schedule		24.14							Fee Schedule		18.5							Fee Schedule		10.49							Fee Schedule		24.3							Fee Schedule		12.06							Fee Schedule		9.76							Fee Schedule											12.06							Fee Schedule		9.76							Fee Schedule		
MEDIHONEY COLLOID 2X2 #31222 (DISC.)	272	RC	A6234	CPT				Both			12.6	5.67	5.67	26.96	5.89							Fee Schedule		9.32							Fee Schedule		9.61							Fee Schedule		7.36							Fee Schedule		23.44							Fee Schedule		11.34							Fee Schedule		26.96							Fee Schedule		21.8							Fee Schedule											26.96							Fee Schedule		21.8							Fee Schedule		
MEDIHONEY COLLOID 41/2X71/2 31445	272	RC						Both			36.75	16.54	8.68	33.08	23.89							Fee Schedule		27.2							Fee Schedule																				9.33							Fee Schedule		33.08							Fee Schedule		10.73							Fee Schedule		8.68							Fee Schedule											10.73							Fee Schedule		8.68							Fee Schedule		
MEDIHONEY COLLOID DSG. 2X2 31422 (DISC.)	272	RC						Both			12.6	5.67	5.67	11.34	8.19							Fee Schedule		9.32							Fee Schedule																													11.34							Fee Schedule																																															
MEDIHONEY COLLOID DSG. 4X5 31245 (DISC.)	272	RC	A6235	CPT				Both			27	12.15	12.15	24.69	15.14							Fee Schedule		19.98							Fee Schedule		24.69							Fee Schedule		18.93							Fee Schedule											24.3							Fee Schedule																																															
MEDIHONEY DSG. 4X4 NONADHESIVE # 31644	272	RC	A6235	CPT				Both			31.82	14.32	14.32	28.64	15.14							Fee Schedule		23.55							Fee Schedule		24.69							Fee Schedule		18.93							Fee Schedule		23.97							Fee Schedule		28.64							Fee Schedule		27.57							Fee Schedule		22.29							Fee Schedule											27.57							Fee Schedule		22.29							Fee Schedule		
MEDIHONEY TUBE 1.5 OZ #31515	272	RC	A6240	CPT				Both			37	16.65	11.02	33.3	11.02							Fee Schedule		27.38							Fee Schedule		17.97							Fee Schedule		13.78							Fee Schedule		23.97							Fee Schedule		33.3							Fee Schedule		27.57							Fee Schedule		22.29							Fee Schedule											27.57							Fee Schedule		22.29							Fee Schedule		
MEDIPORE + PAD 3.5X10  3M #3571	272	RC						Both			3	1.35	1.35	20.07	1.95							Fee Schedule		2.22							Fee Schedule																				17.45							Fee Schedule		2.7							Fee Schedule		20.07							Fee Schedule		16.23							Fee Schedule											20.07							Fee Schedule		16.23							Fee Schedule		
MEDIVATORS ENDO GASTRO KIT #101803	272	RC						Both			44.1	19.85	19.85	39.69	28.67							Fee Schedule		32.63							Fee Schedule																													39.69							Fee Schedule																																															
MEDIVATORS FILTER MF01-0028	270	RC						Both			9.45	4.25	4.25	8.51	6.14							Fee Schedule		6.99							Fee Schedule																													8.51							Fee Schedule																																															
MEDIVATORS FILTER MF01-0069	270	RC						Both			9.45	4.25	4.25	8.51	6.14							Fee Schedule		6.99							Fee Schedule																													8.51							Fee Schedule																																															
MEDIVATORS FILTER MF01-0070	270	RC						Both			9.45	4.25	4.25	8.51	6.14							Fee Schedule		6.99							Fee Schedule																													8.51							Fee Schedule																																															
MEDIVATORS FILTER MF01-0071	270	RC						Both			9.45	4.25	4.25	8.51	6.14							Fee Schedule		6.99							Fee Schedule																													8.51							Fee Schedule																																															
MEDIVATORS PULL THRU BRONCHOSCOPE 100406	270	RC						Both			28.35	12.76	12.76	25.52	18.43							Fee Schedule		20.98							Fee Schedule																													25.52							Fee Schedule																																															
MEDIVATORS SCOPE BUDDY #SB-110HU1007	270	RC						Both			57	25.65	25.65	51.3	37.05							Fee Schedule		42.18							Fee Schedule																													51.3							Fee Schedule																																															
MEDIVATORS SCOPE BUDDY #SB-110HU1012	270	RC						Both			57	25.65	25.65	51.3	37.05							Fee Schedule		42.18							Fee Schedule																													51.3							Fee Schedule																																															
MEDIVATORS SCOPE BUDDY #SB-110HU1012	270	RC						Both			57	25.65	25.65	51.3	37.05							Fee Schedule		42.18							Fee Schedule																													51.3							Fee Schedule																																															
MEDIVATORS SCOPE BUDDY SB-110-HU1007	270	RC						Both			9.45	4.25	4.25	8.51	6.14							Fee Schedule		6.99							Fee Schedule																													8.51							Fee Schedule																																															
MEDIVATORS SCOPE BUDDY SB-110-HU1015	270	RC						Both			9.45	4.25	4.25	8.51	6.14							Fee Schedule		6.99							Fee Schedule																													8.51							Fee Schedule																																															
MEDIVATORS STUBBY BRUSH  100402	270	RC						Both			9.45	4.25	4.25	8.51	6.14							Fee Schedule		6.99							Fee Schedule																													8.51							Fee Schedule																																															
MEDIVATORS STUBBY BRUSH PULL THRU 100405	270	RC						Both			9.45	4.25	4.25	8.51	6.14							Fee Schedule		6.99							Fee Schedule																													8.51							Fee Schedule																																															
MEDLINE CEMENT BOWL 32 OZ.#DYND50320	272	RC						Both			4.2	1.89	1.89	3.78	2.73							Fee Schedule		3.11							Fee Schedule																													3.78							Fee Schedule																																															
MEDLINE GYN ROBOTIC PACK #DYNJT5798	272	RC						Both			225	101.25	101.25	202.5	146.25							Fee Schedule		166.5							Fee Schedule																													202.5							Fee Schedule																																															
MEDROXYPROGEST  2.5MG (PROVERA) TABLET	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
MEDROXYPROGEST 10MG (PROVERA) TABLET	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
MEDROXYPROGESTERONE ACETAT 150MG/ML INJ	636	RC	J1050	CPT				Both			170.1	76.55	76.55	153.09		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	125.87							Fee Schedule																													153.09							Fee Schedule																																															
MEDTRONIC ADMIRAL BALL CATH ADM04008013P	272	RC	C1874	CPT				Both			4470	2011.5	315.17	4023	315.17							Fee Schedule		3307.8							Fee Schedule																													4023							Fee Schedule																																															
MEDTRONIC ADMIRAL BALLOON CATH ADM040250	278	RC	C1874	CPT				Both			7410	3334.5	3334.5	6669		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	5483.4							Fee Schedule																													6669							Fee Schedule																																															
MEDTRONIC ADMIRAL BALLOON CATH ADM050150	278	RC	C1874	CPT				Both			2370	1066.5	1066.5	2133		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1753.8							Fee Schedule																													2133							Fee Schedule																																															
MEDTRONIC ADMIRAL BALLOON CATH ADM060250	278	RC	C1874	CPT				Both			7410	3334.5	3334.5	6669		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	5483.4							Fee Schedule																													6669							Fee Schedule																																															
MEDTRONIC ADMIRAL CATH ADM04012013P	272	RC	C2623	CPT				Both			4920	2214	2214	4428	3198							Fee Schedule		3640.8							Fee Schedule																													4428							Fee Schedule																																															
MEDTRONIC ADMIRAL CATH ADM05006013P	272	RC	C2623	CPT				Both			4470	2011.5	2011.5	4023	2905.5							Fee Schedule		3307.8							Fee Schedule																													4023							Fee Schedule																																															
MEDTRONIC ADMIRAL CATH ADM05015013P	272	RC	C2623	CPT				Both			9885	4448.25	4448.25	8896.5	6425.25							Fee Schedule		7314.9							Fee Schedule																													8896.5							Fee Schedule																																															
MEDTRONIC ADMIRAL CATH ADM05025013P	272	RC	C2623	CPT				Both			9885	4448.25	4448.25	8896.5	6425.25							Fee Schedule		7314.9							Fee Schedule																													8896.5							Fee Schedule																																															
MEDTRONIC ADMIRAL CATH ADM06004013P	272	RC	C2623	CPT				Both			4470	2011.5	2011.5	4023	2905.5							Fee Schedule		3307.8							Fee Schedule																													4023							Fee Schedule																																															
MEDTRONIC APTUS SHEATH TG0655509	272	RC	C1887	CPT				Both			1811.25	815.06	43.86	1630.13	43.86							Fee Schedule		1340.33							Fee Schedule																													1630.13							Fee Schedule																																															
MEDTRONIC APTUS SHEATH TG0705509	272	RC	C1887	CPT				Both			1725	776.25	43.86	1552.5	43.86							Fee Schedule		1276.5							Fee Schedule																													1552.5							Fee Schedule																																															
MEDTRONIC EXTERNALNEUROSTIMULATOR 3531	272	RC	L8681	CPT				Both			1260	567	567	1440.28	577							Fee Schedule		932.4							Fee Schedule		1440.28							Fee Schedule																				1134							Fee Schedule																																															
MEDTRONIC GOODE-T-TUBE #1011030	272	RC						Both			81.9	36.86	36.86	1608.08	53.24							Fee Schedule		60.61							Fee Schedule																				1398.33							Fee Schedule		73.71							Fee Schedule		1608.08							Fee Schedule		1300.45							Fee Schedule											1608.08							Fee Schedule		1300.45							Fee Schedule		
MEDTRONIC GOODE-T-TUBE 1016010	272	RC						Both			176	79.2	79.2	158.4	114.4							Fee Schedule		130.24							Fee Schedule																													158.4							Fee Schedule																																															
MEDTRONIC INT. II ANTENNA 37092	272	RC						Both			252	113.4	113.4	226.8	163.8							Fee Schedule		186.48							Fee Schedule																													226.8							Fee Schedule																																															
MEDTRONIC INTERSTIM 3576-25	278	RC	L8629	CPT				Both			252	113.4	113.4	228.32		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	186.48							Fee Schedule		228.32							Fee Schedule																				226.8							Fee Schedule																																															
MEDTRONIC INTERSTIM 3576-64	272	RC						Both			252	113.4	113.4	254.92	163.8							Fee Schedule		186.48							Fee Schedule																				221.67							Fee Schedule		226.8							Fee Schedule		254.92							Fee Schedule		206.15							Fee Schedule											254.92							Fee Schedule		206.15							Fee Schedule		
MEDTRONIC INTERSTIM II 3058	278	RC	C1767	CPT				Both			36792	16556.4	16556.4	33112.8		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	27226.08							Fee Schedule																													33112.8							Fee Schedule																																															
MEDTRONIC INTERSTIM II PROGRAMMER 3037	272	RC	C1787	CPT				Both			4011	1804.95	35.29	3609.9	35.29							Fee Schedule		2968.14							Fee Schedule																													3609.9							Fee Schedule																																															
MEDTRONIC INTRODUCER SHEATH SENSH1464W	272	RC	C1769	CPT				Both			630	283.5	154.26	567	154.26							Fee Schedule		466.2							Fee Schedule																													567							Fee Schedule																																															
MEDTRONIC LEAD INTRODUCER KIT #3550-18	272	RC	C1894	CPT				Both			1011.15	455.02	87.34	910.04	87.34							Fee Schedule		748.25							Fee Schedule																													910.04							Fee Schedule																																															
MEDTRONIC MINI HOOK CABLE  357501	272	RC						Both			126	56.7	56.7	113.4	81.9							Fee Schedule		93.24							Fee Schedule																													113.4							Fee Schedule																																															
MEDTRONIC SHEATH TG0704509	272	RC	C1887	CPT				Both			1811.25	815.06	43.86	1630.13	43.86							Fee Schedule		1340.33							Fee Schedule																													1630.13							Fee Schedule																																															
MEDTRONIC SNS LEAD #3093  (MEDTRONIC )	278	RC	C1778	CPT				Both			9198	4139.1	4139.1	8278.2		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	6806.52							Fee Schedule																													8278.2							Fee Schedule																																															
MEDTRONIC SNS LEAD 3889-28	278	RC	L8680	CPT				Both			11198.25	5039.21	5039.21	10078.43		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	8286.71							Fee Schedule																													10078.43							Fee Schedule																																															
MEDTRONIC STEERABLE SHEAT  90cmTG0709009	272	RC	C1887	CPT				Both			1908	858.6	43.86	1717.2	43.86							Fee Schedule		1411.92							Fee Schedule																													1717.2							Fee Schedule																																															
MEDTRONIC STEERABLE SHEATH TG0654509	272	RC	C1887	CPT				Both			1811.25	815.06	43.86	1630.13	43.86							Fee Schedule		1340.33							Fee Schedule																													1630.13							Fee Schedule																																															
MEDTRONIC STEERABLE SHEETH TG0655517	272	RC	C1887	CPT				Both			1725	776.25	43.86	1552.5	43.86							Fee Schedule		1276.5							Fee Schedule																													1552.5							Fee Schedule																																															
MEDTRONIC STENT SYSTEM AB9U14060090	278	RC	C1876	CPT				Both			5685	2558.25	2558.25	5116.5		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	4206.9							Fee Schedule																													5116.5							Fee Schedule																																															
MEDTRONIC STENT SYSTEM AB9U14080090	278	RC	C1876	CPT				Both			5685	2558.25	2558.25	5116.5		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	4206.9							Fee Schedule																													5116.5							Fee Schedule																																															
MEDTRONIC STENT SYSTEM AB9U16060090	278	RC	C1876	CPT				Both			5685	2558.25	2558.25	5116.5		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	4206.9							Fee Schedule																													5116.5							Fee Schedule																																															
MEDTRONIC STENT SYSTEM AB9U16080090	278	RC	C1876	CPT				Both			5685	2558.25	2558.25	5116.5		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	4206.9							Fee Schedule																													5116.5							Fee Schedule																																															
MEDTRONIC STENT SYSTEM AB9U16100090	278	RC	C1876	CPT				Both			5685	2558.25	2558.25	5116.5		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	4206.9							Fee Schedule																													5116.5							Fee Schedule																																															
MEDTRONIC STENT SYSTEM AB9U16150090	278	RC	C1876	CPT				Both			6375	2868.75	2868.75	5737.5		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	4717.5							Fee Schedule																													5737.5							Fee Schedule																																															
MEDTRONIC VALVED INFUS. CATH. 41058-01	272	RC	C1751	CPT				Both			294	132.3	69.11	264.6	69.11							Fee Schedule		217.56							Fee Schedule																													264.6							Fee Schedule																																															
MEDULLARY REAMER HEAD 10mm 352.100	272	RC						Both			1701	765.45	765.45	1530.9	1105.65							Fee Schedule		1258.74							Fee Schedule																													1530.9							Fee Schedule																																															
MEDULLARY REAMER HEAD 11mm 352.110	272	RC						Both			1701	765.45	765.45	1530.9	1105.65							Fee Schedule		1258.74							Fee Schedule																													1530.9							Fee Schedule																																															
MEDULLARY REAMER HEAD 8.5mm 352.085	272	RC						Both			1701	765.45	765.45	1530.9	1105.65							Fee Schedule		1258.74							Fee Schedule																													1530.9							Fee Schedule																																															
MEDULLARY REAMER HEAD 9.0mm 352.090	272	RC						Both			1701	765.45	765.45	1530.9	1105.65							Fee Schedule		1258.74							Fee Schedule																													1530.9							Fee Schedule																																															
MEDULLARY REAMER HEAD 9.5mm 352.095	272	RC						Both			1701	765.45	765.45	1530.9	1105.65							Fee Schedule		1258.74							Fee Schedule																													1530.9							Fee Schedule																																															
MEFANAMIC ACID 250 MG CAPSULE UD	250	RC	A9270	CPT				Both			4.2	1.89	0.01	3.78	0.01							Fee Schedule		3.11							Fee Schedule																													3.78							Fee Schedule																																															
MEFIX ROLL	271	RC						Both			10.76	4.84	4.84	9.68	6.99							Fee Schedule		7.96							Fee Schedule																													9.68							Fee Schedule																																															
MEGESTROL 20MG (MEGACE) TABLET	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
MEGESTROL 400 MG/ 10ML (MEGACE) SUSP	250	RC	A9270	CPT				Both			13.32	5.99	0.01	11.99	0.01							Fee Schedule		9.86							Fee Schedule																													11.99							Fee Schedule																																															
MEGESTROL 40MG (MEGACE) TABLET	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
MELATONIN TABLET 3MG	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
MELLARIL 100MG TABS	250	RC	A9270	CPT				Both			1.58	0.71	0.01	1.42	0.01							Fee Schedule		1.17							Fee Schedule																													1.42							Fee Schedule																																															
MELOXICAM 7.5MG (MOBIC) TABLET	250	RC	A9270	CPT				Both			12.6	5.67	0.01	11.34	0.01							Fee Schedule		9.32							Fee Schedule																													11.34							Fee Schedule																																															
MEMANTINE HCL 10MG (NAMENDA) TABLET	250	RC	A9270	CPT				Both			18.9	8.51	0.01	17.01	0.01							Fee Schedule		13.99							Fee Schedule																													17.01							Fee Schedule																																															
MEMORY II BASKET MWB5-1.5	272	RC						Both			422.1	189.95	189.95	379.89	274.37							Fee Schedule		312.35							Fee Schedule																													379.89							Fee Schedule																																															
MEN2 & FMTC MUTATIONS 36587 EDTA 5ML	300	RC	81404	CPT				Both			1202.25	541.01	197.88	1082.03	197.88							Fee Schedule		274.83							Fee Schedule		283.07							Fee Schedule		274.83							Fee Schedule											1082.03							Fee Schedule																				274.83							Fee Schedule																				
MENACTRA 4 MCG/0.5ML VACCINE	636	RC	90734	CPT				Both			143.85	64.73	64.73	316.05		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	106.45							Fee Schedule																				274.83							Fee Schedule		129.47							Fee Schedule		316.05							Fee Schedule		255.59							Fee Schedule											316.05							Fee Schedule		255.59							Fee Schedule		
MENISCAL REPAIR SYSTEM #7209485	278	RC	C1713	CPT				Both			362.25	163.01	163.01	326.03		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	268.07							Fee Schedule																													326.03							Fee Schedule																																															
MENISESTURY BOVIE TP	272	RC						Both			68.25	30.71	30.71	61.43	44.36							Fee Schedule		50.51							Fee Schedule																													61.43							Fee Schedule																																															
MENOMUNE VACCINE	636	RC	90733	CPT				Both			114.45	51.5	51.5	103.01		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	84.69							Fee Schedule											93.36							Fee Schedule											103.01							Fee Schedule																																															
MENQUADFI 0.5ML VACCINE	636	RC	90619	CPT				Both			534.9	240.71	240.71	481.41		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	395.83							Fee Schedule																													481.41							Fee Schedule																																															
FOOT PROCEDURES WITH CC					504	DRG		Inpatient			14899.6	6704.82	6704.82	6704.82							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period	
MENTOR ASEPTIC FLUID XFER SET #350-8400	272	RC						Both			75.6	34.02	34.02	68.04	49.14							Fee Schedule		55.94							Fee Schedule																													68.04							Fee Schedule																																															
MENVEO 0.5ML VACCINE	636	RC	90734	CPT				Both			147	66.15	66.15	132.3		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	108.78							Fee Schedule																													132.3							Fee Schedule																																															
MENVEO VACCINE 0.5ML SDV	636	RC	90734	CPT				Both			399.9	179.96	179.96	359.91		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	295.93							Fee Schedule																													359.91							Fee Schedule																																															
MEPERIDINE  50 MG/5ML (DEMEROL) SYRUP	250	RC	A9270	CPT				Both			7.35	3.31	0.01	6.62	0.01							Fee Schedule		5.44							Fee Schedule																													6.62							Fee Schedule																																															
MEPERIDINE 10 MG/ML -( DEMEROL ) PCA	636	RC	J2175	CPT				Both			75.6	34.02	1.31	68.04		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	55.94							Fee Schedule		6.53							Fee Schedule		1.31							Fee Schedule											68.04							Fee Schedule																																															
MEPERIDINE 25 MG/ 0.5ML (DEMEROL) *AMP	636	RC	J2175	CPT				Both			11.55	5.2	1.31	10.4		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	8.55							Fee Schedule		6.53							Fee Schedule		1.31							Fee Schedule		6.34							Fee Schedule		10.4							Fee Schedule		7.29							Fee Schedule		5.9							Fee Schedule											7.29							Fee Schedule		5.9							Fee Schedule		
MEPERIDINE 25 MG/ML (DEMEROL) INJ	636	RC	J2175	CPT				Both			12.6	5.67	1.31	11.34		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	9.32							Fee Schedule		6.53							Fee Schedule		1.31							Fee Schedule		6.34							Fee Schedule		11.34							Fee Schedule		7.29							Fee Schedule		5.9							Fee Schedule											7.29							Fee Schedule		5.9							Fee Schedule		
MEPERIDINE 50 MG (DEMEROL) TABLET	250	RC	A9270	CPT				Both			7.35	3.31	0.01	7.29	0.01							Fee Schedule		5.44							Fee Schedule																				6.34							Fee Schedule		6.62							Fee Schedule		7.29							Fee Schedule		5.9							Fee Schedule											7.29							Fee Schedule		5.9							Fee Schedule		
MEPERIDINE 50 MG/ML (DEMEROL) INJ	636	RC	J2175	CPT				Both			12.6	5.67	1.31	11.34		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	9.32							Fee Schedule		6.53							Fee Schedule		1.31							Fee Schedule											11.34							Fee Schedule																																															
MEPERIDINE 75MG/1ML (DEMEROL) INJ	636	RC	J2175	CPT				Both			17.85	8.03	1.31	16.07		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	13.21							Fee Schedule		6.53							Fee Schedule		1.31							Fee Schedule		6.34							Fee Schedule		16.07							Fee Schedule		7.29							Fee Schedule		5.9							Fee Schedule											7.29							Fee Schedule		5.9							Fee Schedule		
MEPERIDINE/PROMETHAZINE 50/25 CAPSULE	250	RC	A9270	CPT				Both			7.35	3.31	0.01	7.29	0.01							Fee Schedule		5.44							Fee Schedule																				6.34							Fee Schedule		6.62							Fee Schedule		7.29							Fee Schedule		5.9							Fee Schedule											7.29							Fee Schedule		5.9							Fee Schedule		
MEPILEX 4X4 DRESSING W/ BORDER	272	RC	A6219	CPT				Both			16	7.2	0.86	14.4	0.86							Fee Schedule		11.84							Fee Schedule		1.4							Fee Schedule		1.08							Fee Schedule											14.4							Fee Schedule																																															
MEPILEX TRANSFER AG 4X5  #394190	272	RC	A6210	CPT				Both			103	46.35	1.26	92.7	17.94							Fee Schedule		76.22							Fee Schedule		29.25							Fee Schedule		22.42							Fee Schedule		1.36							Fee Schedule		92.7							Fee Schedule		1.56							Fee Schedule		1.26							Fee Schedule											1.56							Fee Schedule		1.26							Fee Schedule		
MEPROBAMATE 200 MG TABLET UD	250	RC	A9270	CPT				Both			1.58	0.71	0.01	32.66	0.01							Fee Schedule		1.17							Fee Schedule																				28.4							Fee Schedule		1.42							Fee Schedule		32.66							Fee Schedule		26.41							Fee Schedule											32.66							Fee Schedule		26.41							Fee Schedule		
MEPROBAMATE 635 SERUM	301	RC	80307	CPT				Both			65.1	29.3	29.3	64.65	51.72							Fee Schedule		64.65							Fee Schedule		64							Fee Schedule		62.14							Fee Schedule											58.59							Fee Schedule																				62.14							Fee Schedule																				
MERCAPTOPURINE 50MG TABLET	250	RC	S0108	CPT				Both			6.3	2.84	2.84	71.46	3							Fee Schedule		4.66							Fee Schedule																				62.14							Fee Schedule		5.67							Fee Schedule		71.46							Fee Schedule		57.79							Fee Schedule											71.46							Fee Schedule		57.79							Fee Schedule		
MERCURY BLOOD 636 RB EDTA WB RT	301	RC	83825	CPT				Both			149.1	67.1	14.45	134.19	14.45							Fee Schedule		18.06							Fee Schedule		16.75							Fee Schedule		16.26							Fee Schedule											134.19							Fee Schedule																				16.26							Fee Schedule																				
MERCURY URINE 637 URINE 24HR	301	RC	83825	CPT				Both			149.1	67.1	14.45	134.19	14.45							Fee Schedule		18.06							Fee Schedule		16.75							Fee Schedule		16.26							Fee Schedule		16.26							Fee Schedule		134.19							Fee Schedule		18.7							Fee Schedule		15.12							Fee Schedule		16.26							Fee Schedule		18.7							Fee Schedule		15.12							Fee Schedule		
MEROCEL NASAL DRESSING 440402	272	RC						Both			79	35.55	15.12	71.1	51.35							Fee Schedule		58.46							Fee Schedule																				16.26							Fee Schedule		71.1							Fee Schedule		18.7							Fee Schedule		15.12							Fee Schedule											18.7							Fee Schedule		15.12							Fee Schedule		
MEROPENEM  1GM  PREMIX	250	RC	J2185	CPT				Both			82.95	37.33	0.33	74.66	0.8							Fee Schedule		61.38							Fee Schedule		0.33							Fee Schedule																				74.66							Fee Schedule																																															
MEROPENEM  1GM VIAL	250	RC	J2185	CPT				Both			47.25	21.26	0.3	42.53	0.8							Fee Schedule		34.97							Fee Schedule		0.33							Fee Schedule											0.33							Fee Schedule		42.53							Fee Schedule		0.37							Fee Schedule		0.3							Fee Schedule											0.37							Fee Schedule		0.3							Fee Schedule		
MEROPENEM  500MG PREMIX	250	RC	J2185	CPT				Both			60.9	27.41	0.3	54.81	0.8							Fee Schedule		45.07							Fee Schedule		0.33							Fee Schedule											0.33							Fee Schedule		54.81							Fee Schedule		0.37							Fee Schedule		0.3							Fee Schedule											0.37							Fee Schedule		0.3							Fee Schedule		
MEROPENEM  500MG VIAL	250	RC	J2185	CPT				Both			47.25	21.26	0.3	42.53	0.8							Fee Schedule		34.97							Fee Schedule		0.33							Fee Schedule											0.33							Fee Schedule		42.53							Fee Schedule		0.37							Fee Schedule		0.3							Fee Schedule											0.37							Fee Schedule		0.3							Fee Schedule		
MEROPENEM 1 GM INJECTION	250	RC	J2185	CPT				Both			75.6	34.02	0.3	68.04	0.8							Fee Schedule		55.94							Fee Schedule		0.33							Fee Schedule											0.33							Fee Schedule		68.04							Fee Schedule		0.37							Fee Schedule		0.3							Fee Schedule											0.37							Fee Schedule		0.3							Fee Schedule		
MEROPENEM 10MG/NS 100ML IVPB	250	RC	J2185	CPT				Both			82.95	37.33	0.3	74.66	0.8							Fee Schedule		61.38							Fee Schedule		0.33							Fee Schedule											0.33							Fee Schedule		74.66							Fee Schedule		0.37							Fee Schedule		0.3							Fee Schedule											0.37							Fee Schedule		0.3							Fee Schedule		
MEROPENEM 1GM/NS 100ML IVPB	250	RC	J2185	CPT				Both			47.25	21.26	0.3	42.53	0.8							Fee Schedule		34.97							Fee Schedule		0.33							Fee Schedule											0.33							Fee Schedule		42.53							Fee Schedule		0.37							Fee Schedule		0.3							Fee Schedule											0.37							Fee Schedule		0.3							Fee Schedule		
MERSILENE (5.0) 499T	272	RC						Both			15.75	7.09	0.3	14.18	10.24							Fee Schedule		11.66							Fee Schedule																				0.33							Fee Schedule		14.18							Fee Schedule		0.37							Fee Schedule		0.3							Fee Schedule											0.37							Fee Schedule		0.3							Fee Schedule		
MERSILENE 0 R424	272	RC						Both			11.55	5.2	5.2	10.4	7.51							Fee Schedule		8.55							Fee Schedule																													10.4							Fee Schedule																																															
MERSILENE 2-0 R423	272	RC						Both			23.1	10.4	10.4	20.79	15.02							Fee Schedule		17.09							Fee Schedule																													20.79							Fee Schedule																																															
MERSILENE 4-0 R691G	272	RC						Both			11.55	5.2	5.2	10.4	7.51							Fee Schedule		8.55							Fee Schedule																													10.4							Fee Schedule																																															
MERSILENE 5.0 RS20	272	RC						Both			133.35	60.01	60.01	120.02	86.68							Fee Schedule		98.68							Fee Schedule																													120.02							Fee Schedule																																															
MERSILENE 5MM #RS21	272	RC						Both			135.45	60.95	60.95	121.91	88.04							Fee Schedule		100.23							Fee Schedule																													121.91							Fee Schedule																																															
MESALAMINE (ROWASA) RECTAL ENEMA SUSP	250	RC	A9270	CPT				Both			73.26	32.97	0.01	65.93	0.01							Fee Schedule		54.21							Fee Schedule																													65.93							Fee Schedule																																															
MESALT TOPICAL DRESSING UD	250	RC	A9270	CPT				Both			10.5	4.73	0.01	9.45	0.01							Fee Schedule		7.77							Fee Schedule																													9.45							Fee Schedule																																															
MESH  ANATOMICAL DXT1510AL (MEDTRONIC)	278	RC	C1781	CPT				Both			900	405	405	810		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	666							Fee Schedule																													810							Fee Schedule																																															
MESH  ANATOMICAL DXT1510AR (MEDTRONIC)	278	RC	C1781	CPT				Both			900	405	405	810		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	666							Fee Schedule																													810							Fee Schedule																																															
MESH 10X14 # 0112660  ( BARD/DAVOL )	278	RC	C1781	CPT				Both			309.75	139.39	139.39	278.78		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	229.22							Fee Schedule																													278.78							Fee Schedule																																															
MESH 12X12 (ATRIUM MEDICAL)	278	RC	C1781	CPT				Both			267.75	120.49	120.49	240.98		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	198.14							Fee Schedule																													240.98							Fee Schedule																																															
MESH 1X4 # 0112640  ( BARD/DAVOL )	278	RC	C1781	CPT				Both			87	39.15	39.15	78.3		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	64.38							Fee Schedule																													78.3							Fee Schedule																																															
MESH 3D MAX BARD # 0116311	278	RC	C1781	CPT				Both			753	338.85	338.85	677.7		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	557.22							Fee Schedule																													677.7							Fee Schedule																																															
MESH 3D MAX BARD # 0116312  DAVOL	278	RC	C1781	CPT				Both			830	373.5	373.5	747		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	614.2							Fee Schedule																													747							Fee Schedule																																															
MESH 3D MAX BARD # 0116321	278	RC	C1781	CPT				Both			753	338.85	338.85	677.7		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	557.22							Fee Schedule																													677.7							Fee Schedule																																															
MESH 3D MAX BARD # 0116322  DAVOL	278	RC	C1781	CPT				Both			830	373.5	373.5	747		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	614.2							Fee Schedule																													747							Fee Schedule																																															
MESH 3X3  (ATRIUM) 1000303-00	278	RC	C1781	CPT				Both			94.5	42.53	42.53	85.05		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	69.93							Fee Schedule																													85.05							Fee Schedule																																															
MESH 3X6 # 0112680  ( BARD/DAVOL )	278	RC	C1781	CPT				Both			114	51.3	51.3	102.6		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	84.36							Fee Schedule																													102.6							Fee Schedule																																															
MESH 3X6 (ATRIUM)1000306-00	278	RC	C1781	CPT				Both			112.35	50.56	50.56	101.12		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	83.14							Fee Schedule																													101.12							Fee Schedule																																															
MESH 6X6 # 0112720 ( BARD/DAVOL )	278	RC	C1781	CPT				Both			330	148.5	148.5	297		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	244.2							Fee Schedule																													297							Fee Schedule																																															
MESH 6X6 (ATRIUM)1000606-00	278	RC	C1781	CPT				Both			98.18	44.18	44.18	88.36		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	72.65							Fee Schedule																													88.36							Fee Schedule																																															
MESH MARLEX BARD DAVOL #0112660	278	RC	C1781	CPT				Both			557.55	250.9	250.9	501.8		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	412.59							Fee Schedule																													501.8							Fee Schedule																																															
MESH OVITEX CORE 6X10 # F10254-0610G	278	RC	C1781	CPT				Both			1620	729	729	1458		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1198.8							Fee Schedule																													1458							Fee Schedule																																															
MESH VENTRALIGHT 5954450 BARD DAVOL	278	RC	C1781	CPT				Both			1439	647.55	647.55	1295.1		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1064.86							Fee Schedule																													1295.1							Fee Schedule																																															
MESH VENTRALIGHT 5954460 BARD DAVOL	278	RC	C1781	CPT				Both			1214	546.3	546.3	1092.6		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	898.36							Fee Schedule																													1092.6							Fee Schedule																																															
MESH VENTRALIGHT 5954600 BARD DAVOL	278	RC	C1781	CPT				Both			1913	860.85	860.85	1721.7		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1415.62							Fee Schedule																													1721.7							Fee Schedule																																															
MESH VENTRALIGHT 5954680 BARD DAVOL	278	RC	C1781	CPT				Both			2448	1101.6	1101.6	2203.2		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1811.52							Fee Schedule																													2203.2							Fee Schedule																																															
MESH VENTRALIGHT 5954810 BARD DAVOL	278	RC	C1781	CPT				Both			3792	1706.4	1706.4	3412.8		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	2806.08							Fee Schedule																													3412.8							Fee Schedule																																															
MESH VENTRALIGHT ECHO 5990015 BARD DAVOL	278	RC	C1781	CPT				Both			2952	1328.4	1328.4	2656.8		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	2184.48							Fee Schedule																													2656.8							Fee Schedule																																															
MESH V-PATCH 2.5 X 2.5 # 31201 (ATRUIM)	278	RC	C1781	CPT				Both			1388.63	624.88	624.88	1249.77		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1027.59							Fee Schedule																													1249.77							Fee Schedule																																															
MESH V-PATCH 3.2 X 3.2 31202 (ATRIUM)	278	RC	C1781	CPT				Both			1804.95	812.23	812.23	1624.46		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1335.66							Fee Schedule																													1624.46							Fee Schedule																																															
MESTINON 60 MG TABLET UD	250	RC	A9270	CPT				Both			5.25	2.36	0.01	4.73	0.01							Fee Schedule		3.89							Fee Schedule																													4.73							Fee Schedule																																															
MESTINON SYR:PER OZ	250	RC						Both			6.58	2.96	2.96	5.92	4.28							Fee Schedule		4.87							Fee Schedule																													5.92							Fee Schedule																																															
METAL LEG SPLINT LONG	274	RC	L2116	CPT				Both			296.1	133.25	133.25	905.12		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	219.11							Fee Schedule		905.12							Fee Schedule		622.43							Fee Schedule											266.49							Fee Schedule																																															
METAL LEG SPLINT SHRT	274	RC	L2116	CPT				Both			255.15	114.82	114.82	1010.57		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	188.81							Fee Schedule		905.12							Fee Schedule		622.43							Fee Schedule		878.76							Fee Schedule		229.64							Fee Schedule		1010.57							Fee Schedule		817.25							Fee Schedule											1010.57							Fee Schedule		817.25							Fee Schedule		
METAMUCIL CAPSULE UD	250	RC	A9270	CPT				Both			5.25	2.36	0.01	1010.57	0.01							Fee Schedule		3.89							Fee Schedule																				878.76							Fee Schedule		4.73							Fee Schedule		1010.57							Fee Schedule		817.25							Fee Schedule											1010.57							Fee Schedule		817.25							Fee Schedule		
METAMUCIL PWD	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
METANEPHRINES FRAC RAND UR 14961	301	RC	83835	CPT				Both			195	87.75	15.06	175.5	15.06							Fee Schedule		18.82							Fee Schedule		17.45							Fee Schedule		16.94							Fee Schedule											175.5							Fee Schedule																				16.94							Fee Schedule																				
METANEPHRINES FRACT PLASMA 19548	301	RC	83835	CPT				Both			214.2	96.39	15.06	192.78	15.06							Fee Schedule		18.82							Fee Schedule		17.45							Fee Schedule		16.94							Fee Schedule		16.94							Fee Schedule		192.78							Fee Schedule		19.48							Fee Schedule		15.75							Fee Schedule		16.94							Fee Schedule		19.48							Fee Schedule		15.75							Fee Schedule		
METANEPHRINES FRACTIONATED 14962 UR 24HR	301	RC	83835	CPT				Both			154.35	69.46	15.06	138.92	15.06							Fee Schedule		18.82							Fee Schedule		17.45							Fee Schedule		16.94							Fee Schedule		16.94							Fee Schedule		138.92							Fee Schedule		19.48							Fee Schedule		15.75							Fee Schedule		16.94							Fee Schedule		19.48							Fee Schedule		15.75							Fee Schedule		
METAPROTERENOL 0.4% 2.5ML UD(RT)	636	RC	J7668	CPT				Both			5.25	2.36	2.36	19.48		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	3.89							Fee Schedule																				16.94							Fee Schedule		4.73							Fee Schedule		19.48							Fee Schedule		15.75							Fee Schedule											19.48							Fee Schedule		15.75							Fee Schedule		
METAPROTERENOL 10MG/5ML SYRUP	250	RC	A9270	CPT				Both			2.38	1.07	0.01	2.14	0.01							Fee Schedule		1.76							Fee Schedule																													2.14							Fee Schedule																																															
METARAMINOL 10 MG/ML VIAL-10M (PER ML)	636	RC	J0380	CPT				Both			4.2	1.89	1.89	3.78		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	3.11							Fee Schedule																													3.78							Fee Schedule																																															
METAXALONE (SKELAXIN) 800MG TABLET	250	RC	A9270	CPT				Both			8.4	3.78	0.01	7.56	0.01							Fee Schedule		6.22							Fee Schedule																													7.56							Fee Schedule																																															
METAXALONE 400 MG TABLET UD	250	RC	A9270	CPT				Both			4.2	1.89	0.01	3.78	0.01							Fee Schedule		3.11							Fee Schedule																													3.78							Fee Schedule																																															
metFORMIN 500MG (GLUCOPHAGE) TABLET	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
metFORMIN 850MG (GLUCOPHAGE) TABLET	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
metFORMIN ER 500MG (GLUCOPHAGE) TABLET	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
metFORMIN ER 750MG (GLUCOPHAGE) TABLET	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
METHACHOLINE CHALLENGE	460	RC	94070	CPT				Both			579.6	260.82	44.63	521.64	200							Per Diem		428.9							Fee Schedule											44.63							Fee Schedule											521.64							Fee Schedule																				318							Per Diem																				
METHADONE  5 MG TABLET	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
METHADONE 10 MG TABLET	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
METHADONE 3258 SERUM 4ML RT	301	RC	80307	CPT				Both			149.1	67.1	51.72	134.19	51.72							Fee Schedule		64.65							Fee Schedule		64							Fee Schedule		62.14							Fee Schedule											134.19							Fee Schedule																				62.14							Fee Schedule																				
METHADONE 40 MG TABLET	250	RC	A9270	CPT				Both			6.3	2.84	0.01	71.46	0.01							Fee Schedule		4.66							Fee Schedule																				62.14							Fee Schedule		5.67							Fee Schedule		71.46							Fee Schedule		57.79							Fee Schedule											71.46							Fee Schedule		57.79							Fee Schedule		
METHADONE AND METABOLITE URINE 15714	301	RC	80358	CPT				Both			136.35	61.36	0.01	122.72	0.01							Fee Schedule									Other	No Additional Reimbursement 																												122.72							Fee Schedule																																															
METHADONE URINE 30468 RANDOM URINE	300	RC	80307	CPT				Both			178.5	80.33	51.72	160.65	51.72							Fee Schedule		64.65							Fee Schedule		64							Fee Schedule		62.14							Fee Schedule											160.65							Fee Schedule																				62.14							Fee Schedule																				
METHAMPHETAMINE SERUM 6028	301	RC	80307	CPT				Both			145.95	65.68	51.72	131.36	51.72							Fee Schedule		64.65							Fee Schedule		64							Fee Schedule		62.14							Fee Schedule		62.14							Fee Schedule		131.36							Fee Schedule		71.46							Fee Schedule		57.79							Fee Schedule		62.14							Fee Schedule		71.46							Fee Schedule		57.79							Fee Schedule		
METHAMPHETAMINES URINE 241  4ML	300	RC	80307	CPT				Both			276.15	124.27	51.72	248.54	51.72							Fee Schedule		64.65							Fee Schedule		64							Fee Schedule		62.14							Fee Schedule		62.14							Fee Schedule		248.54							Fee Schedule		71.46							Fee Schedule		57.79							Fee Schedule		62.14							Fee Schedule		71.46							Fee Schedule		57.79							Fee Schedule		
METHANOL 643	301	RC	84600	CPT				Both			89.25	40.16	14.29	80.33	14.29							Fee Schedule		17.87							Fee Schedule		17.62							Fee Schedule		17.11							Fee Schedule		62.14							Fee Schedule		80.33							Fee Schedule		71.46							Fee Schedule		57.79							Fee Schedule		17.11							Fee Schedule		71.46							Fee Schedule		57.79							Fee Schedule		
METHANOL URINE 10533	301	RC	84600	CPT				Both			100.8	45.36	14.29	90.72	14.29							Fee Schedule		17.87							Fee Schedule		17.62							Fee Schedule		17.11							Fee Schedule		17.11							Fee Schedule		90.72							Fee Schedule		19.68							Fee Schedule		15.91							Fee Schedule		17.11							Fee Schedule		19.68							Fee Schedule		15.91							Fee Schedule		
METHEGLENE BLUE	250	RC	A9270	CPT				Both			2.1	0.95	0.01	19.68	0.01							Fee Schedule		1.55							Fee Schedule																				17.11							Fee Schedule		1.89							Fee Schedule		19.68							Fee Schedule		15.91							Fee Schedule											19.68							Fee Schedule		15.91							Fee Schedule		
METHEMOGLOBIN 647	301	RC	82657	CPT				Both			57.75	25.99	16.05	51.98	16.05							Fee Schedule		22.17							Fee Schedule		22.84							Fee Schedule		22.17							Fee Schedule											51.98							Fee Schedule																				22.17							Fee Schedule																				
METHERGINE 0.2 MG TAB	250	RC	A9270	CPT				Both			2.1	0.95	0.01	25.5	0.01							Fee Schedule		1.55							Fee Schedule																				22.17							Fee Schedule		1.89							Fee Schedule		25.5							Fee Schedule		20.62							Fee Schedule											25.5							Fee Schedule		20.62							Fee Schedule		
METHERGINE 0.2 MG TABLET	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
METHERGINE 0.2 MG(METHYLERGONOVINE) INJ	636	RC	J2210	CPT				Both			11.55	5.2	4.07	22.2		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	8.55							Fee Schedule		22.2							Fee Schedule		4.07							Fee Schedule											10.4							Fee Schedule																																															
METHERGINE 0.2MG	250	RC						Both			10.5	4.73	4.73	24.78	6.83							Fee Schedule		7.77							Fee Schedule																				21.55							Fee Schedule		9.45							Fee Schedule		24.78							Fee Schedule		20.04							Fee Schedule											24.78							Fee Schedule		20.04							Fee Schedule		
METHIMAZOLE 10MG (TAPAZOLE) TABLET	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
METHOCARBAMOL (ROBAXIN)1000 MG/10ML SDV	636	RC	J2800	CPT				Both			249.9	112.46	4.64	224.91		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	184.93							Fee Schedule		4.64							Fee Schedule		6.21							Fee Schedule											224.91							Fee Schedule																																															
METHOCARBAMOL 500MG (ROBAXIN) TABLET	250	RC	A9270	CPT				Both			5.25	2.36	0.01	5.19	0.01							Fee Schedule		3.89							Fee Schedule																				4.51							Fee Schedule		4.73							Fee Schedule		5.19							Fee Schedule		4.19							Fee Schedule											5.19							Fee Schedule		4.19							Fee Schedule		
METHOCARBAMOL 6200	301	RC	80299	CPT				Both			133.35	60.01	13.42	120.02	13.42							Fee Schedule		18.64							Fee Schedule		19.2							Fee Schedule		18.64							Fee Schedule											120.02							Fee Schedule																				18.64							Fee Schedule																				
METHOCARBAMOL 750MG (ROBAXIN) TABLET	250	RC	A9270	CPT				Both			6.3	2.84	0.01	21.44	0.01							Fee Schedule		4.66							Fee Schedule																				18.64							Fee Schedule		5.67							Fee Schedule		21.44							Fee Schedule		17.34							Fee Schedule											21.44							Fee Schedule		17.34							Fee Schedule		
METHOTREXATE 125 MG/5ML SYRINGE KIT	636	RC	J9260	CPT				Both			787.5	354.38	3.03	708.75		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	582.75							Fee Schedule		3.03							Fee Schedule		7.48							Fee Schedule											708.75							Fee Schedule																																															
METHOTREXATE 2.5 MG TABLET	636	RC	J8610	CPT				Both			14.7	6.62	0.16	13.23		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	10.88							Fee Schedule		0.16							Fee Schedule											2.94							Fee Schedule		13.23							Fee Schedule		3.38							Fee Schedule		2.74							Fee Schedule											3.38							Fee Schedule		2.74							Fee Schedule		
METHOTREXATE 20 MG/ML INJECTION	636	RC	J9250	CPT				Both			44.1	19.85	0.14	39.69		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	32.63							Fee Schedule																				0.15							Fee Schedule		39.69							Fee Schedule		0.18							Fee Schedule		0.14							Fee Schedule											0.18							Fee Schedule		0.14							Fee Schedule		
METHOTREXATE 25 MG/ML- 10ML VIAL	636	RC	J9260	CPT				Both			32.52	14.63	3.03	29.27		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	24.06							Fee Schedule		3.03							Fee Schedule		7.48							Fee Schedule											29.27							Fee Schedule																																															
METHOTREXATE 25 MG/ML- 2ML INJECTION	636	RC	J9250	CPT				Both			15.23	6.85	2.74	13.71		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	11.27							Fee Schedule																				2.94							Fee Schedule		13.71							Fee Schedule		3.38							Fee Schedule		2.74							Fee Schedule											3.38							Fee Schedule		2.74							Fee Schedule		
METHOTREXATE 25MG/ML- 10ML INJECTION	636	RC	J9260	CPT				Both			32.52	14.63	3.03	29.27		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	24.06							Fee Schedule		3.03							Fee Schedule		7.48							Fee Schedule											29.27							Fee Schedule																																															
METHOTREXATE 648 SERUM FROZEN	301	RC	80299	CPT				Both			90.3	40.64	2.74	81.27	13.42							Fee Schedule		18.64							Fee Schedule		19.2							Fee Schedule		18.64							Fee Schedule		2.94							Fee Schedule		81.27							Fee Schedule		3.38							Fee Schedule		2.74							Fee Schedule		18.64							Fee Schedule		3.38							Fee Schedule		2.74							Fee Schedule		
METHOTREXATER 2.5 TA	250	RC						Both			9.03	4.06	4.06	21.44	5.87							Fee Schedule		6.68							Fee Schedule																				18.64							Fee Schedule		8.13							Fee Schedule		21.44							Fee Schedule		17.34							Fee Schedule											21.44							Fee Schedule		17.34							Fee Schedule		
METHSUXIMIDE 21361 SERUM	301	RC	80307	CPT				Both			52.5	23.63	23.63	64.65	51.72							Fee Schedule		64.65							Fee Schedule		64							Fee Schedule		62.14							Fee Schedule											47.25							Fee Schedule																				62.14							Fee Schedule																				
METHYLDOPA 250 MG/5ML (ALDOMET) INJECT	636	RC	J0210	CPT				Both			157.5	70.88	10.37	141.75		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	116.55							Fee Schedule											10.37							Fee Schedule		62.14							Fee Schedule		141.75							Fee Schedule		71.46							Fee Schedule		57.79							Fee Schedule											71.46							Fee Schedule		57.79							Fee Schedule		
METHYLDOPA 250MG (ALDOMET) TABLET	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
METHYLENE BLUE 0.5% 10ML	250	RC	Q9968	CPT				Both			937.55	421.9	10.1	843.8	13.94							Fee Schedule									Other	No Additional Reimbursement 	10.1							Fee Schedule																				843.8							Fee Schedule																																															
METHYLMALONIC ACID 34879 2 ML SER RT	301	RC	83921	CPT				Both			277.2	124.74	9.12	249.48	15.27							Fee Schedule		21.21							Fee Schedule		21.85							Fee Schedule		21.21							Fee Schedule		9.81							Fee Schedule		249.48							Fee Schedule		11.28							Fee Schedule		9.12							Fee Schedule		21.21							Fee Schedule		11.28							Fee Schedule		9.12							Fee Schedule		
METHYLPHENIDATE 5 MG TABLET UD	250	RC	A9270	CPT				Both			6.3	2.84	0.01	24.39	0.01							Fee Schedule		4.66							Fee Schedule																				21.21							Fee Schedule		5.67							Fee Schedule		24.39							Fee Schedule		19.73							Fee Schedule											24.39							Fee Schedule		19.73							Fee Schedule		
METHYLPHENIDATE URINE 90246 20 ML URINE	301	RC	80360	CPT				Both			136.5	61.43	0.01	122.85	0.01							Fee Schedule									Other	No Additional Reimbursement 																												122.85							Fee Schedule																																															
MethylPREDNIsilone 4 MG TABLET	636	RC	J7509	CPT				Both			4.5	2.03	0.16	4.05		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	3.33							Fee Schedule		0.16							Fee Schedule																				4.05							Fee Schedule																																															
METOCLOPRAMIDE  5 MG/5ML ORAL SOLUTION	250	RC	A9270	CPT				Both			4.2	1.89	0.01	3.78	0.01							Fee Schedule		3.11							Fee Schedule																				0.16							Fee Schedule		3.78							Fee Schedule		0.18							Fee Schedule		0.15							Fee Schedule											0.18							Fee Schedule		0.15							Fee Schedule		
METOCLOPRAMIDE  5MG (REGLAN) TABLET	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
METOCLOPRAMIDE 10 MG/10ML(REGLAN) SYRUP	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
METOCLOPRAMIDE 10 MG/2ML (REGLAN) INJ	636	RC	J2765	CPT				Both			12.6	5.67	1.03	11.34		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	9.32							Fee Schedule		1.03							Fee Schedule		2.69							Fee Schedule											11.34							Fee Schedule																																															
METOCLOPRAMIDE 10MG (REGLAN) TABLET	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																				1							Fee Schedule		5.67							Fee Schedule		1.15							Fee Schedule		0.93							Fee Schedule											1.15							Fee Schedule		0.93							Fee Schedule		
METOCLOPRAMIDE 10MG/2ML SYRINGE	636	RC	J2765	CPT				Both			31.5	14.18	1.03	28.35		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	23.31							Fee Schedule		1.03							Fee Schedule		2.69							Fee Schedule											28.35							Fee Schedule																																															
METOCLOPRAMIDE(REGLAN) 20MG/NS 50ML IVPB	636	RC	J2765	CPT				Both			31.19	14.04	0.93	28.07		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	23.08							Fee Schedule		1.03							Fee Schedule		2.69							Fee Schedule		1							Fee Schedule		28.07							Fee Schedule		1.15							Fee Schedule		0.93							Fee Schedule											1.15							Fee Schedule		0.93							Fee Schedule		
METOCLOPRAMIDE(REGLAN)10MG/NS 50ML IVPB	636	RC	J2765	CPT				Both			31.19	14.04	0.93	28.07		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	23.08							Fee Schedule		1.03							Fee Schedule		2.69							Fee Schedule		1							Fee Schedule		28.07							Fee Schedule		1.15							Fee Schedule		0.93							Fee Schedule											1.15							Fee Schedule		0.93							Fee Schedule		
METOLAZONE 2.5MG (ZAROXOLYN) TABLET	250	RC	A9270	CPT				Both			10.5	4.73	0.01	9.45	0.01							Fee Schedule		7.77							Fee Schedule																				1							Fee Schedule		9.45							Fee Schedule		1.15							Fee Schedule		0.93							Fee Schedule											1.15							Fee Schedule		0.93							Fee Schedule		
METOPROLOL  25MG (LOPRESSOR) TABLET	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
METOPROLOL  50MG (LOPRESSOR) TABLET	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
METOPROLOL 100 MG (LOPRESSOR)	250	RC	A9270	CPT				Both			4.2	1.89	0.01	3.78	0.01							Fee Schedule		3.11							Fee Schedule																													3.78							Fee Schedule																																															
METOPROLOL 100MG (LOPRESSOR) TABLET	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
METOPROLOL 5 MG/5ML (LOPRESSOR) INJ	250	RC	A9270	CPT				Both			12.6	5.67	0.01	11.34	0.01							Fee Schedule		9.32							Fee Schedule																													11.34							Fee Schedule																																															
METOPROLOL-ER  25 MG (TOPROL XL) TABLET	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
METOPROLOL-ER  50 MG (TOPROL XL) TABLET	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
METRONIDAZOLE 0.75% VAG (VANDAZOLE) GEL	250	RC	A9270	CPT				Both			321.3	144.59	0.01	289.17	0.01							Fee Schedule		237.76							Fee Schedule																													289.17							Fee Schedule																																															
metroNIDAZOLE 250MG (FLAGYL) TABLET	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
metroNIDAZOLE 500MG (FLAGYL) TABLET	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
metroNIDAZOLE 500MG/100ML PREMIX	636	RC	J1836	CPT				Both			18.9	8.51	0.03	17.01		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	13.99							Fee Schedule		0.03							Fee Schedule																				17.01							Fee Schedule																																															
MEVACOR 20 MG (LOVASTATIN)	250	RC	A9270	CPT				Both			6.05	2.72	0.01	5.45	0.01							Fee Schedule		4.48							Fee Schedule																				0.03							Fee Schedule		5.45							Fee Schedule		0.04							Fee Schedule		0.03							Fee Schedule											0.04							Fee Schedule		0.03							Fee Schedule		
MEXILETENE 150 MG CAPSULE UD	250	RC	A9270	CPT				Both			5.25	2.36	0.01	4.73	0.01							Fee Schedule		3.89							Fee Schedule																													4.73							Fee Schedule																																															
MEXITIL 200 MG	250	RC	A9270	CPT				Both			2.81	1.26	0.01	2.53	0.01							Fee Schedule		2.08							Fee Schedule																													2.53							Fee Schedule																																															
MFUNC ELECTR ZOLLPED	272	RC						Both			169.05	76.07	76.07	152.15	109.88							Fee Schedule		125.1							Fee Schedule																													152.15							Fee Schedule																																															
MHATP TREPONEMA PALL 34323 SERUM	302	RC	86592	CPT				Both			57.75	25.99	3.79	51.98	3.79							Fee Schedule		4.75							Fee Schedule		4.4							Fee Schedule		4.27							Fee Schedule											51.98							Fee Schedule																				4.27							Fee Schedule																				
MIACALCIN 200 IU/ML(CALCIMAR) INJECTABLE	636	RC	J0630	CPT				Both			185.69	83.56	3.97	167.12		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	137.41							Fee Schedule											17.64							Fee Schedule		4.27							Fee Schedule		167.12							Fee Schedule		4.91							Fee Schedule		3.97							Fee Schedule											4.91							Fee Schedule		3.97							Fee Schedule		
MICARDIS 40 MG (TELMISARTAN) TABLET	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
MICATIN CREAM	250	RC	A9270	CPT				Both			25.39	11.43	0.01	22.85	0.01							Fee Schedule		18.79							Fee Schedule																													22.85							Fee Schedule																																															
MICONAZOLE 2% CREAM- 30 GM	250	RC	A9270	CPT				Both			15.12	6.8	0.01	13.61	0.01							Fee Schedule		11.19							Fee Schedule																													13.61							Fee Schedule																																															
MICONAZOLE 2% VAGINAL CREAM- 45GM	250	RC	A9270	CPT				Both			23.1	10.4	0.01	20.79	0.01							Fee Schedule		17.09							Fee Schedule																													20.79							Fee Schedule																																															
MICRIVASIVE BALLOON CATH H74939171062010	272	RC	C1725	CPT				Both			750	337.5	93.3	675	93.3							Fee Schedule		555							Fee Schedule																													675							Fee Schedule																																															
MICRIVASIVE BALLOON CATH H74939171070470	272	RC	C1725	CPT				Both			750	337.5	93.3	675	93.3							Fee Schedule		555							Fee Schedule																													675							Fee Schedule																																															
MICRO AIRE K-WIRE 1600-635	278	RC						Both			15.75	7.09	7.09	14.18		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	11.66							Fee Schedule																													14.18							Fee Schedule																																															
MICRO AIRE K-WIRE 1600-662	278	RC						Both			15.75	7.09	7.09	14.18		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	11.66							Fee Schedule																													14.18							Fee Schedule																																															
MICRO AIRE K-WIRE 1600-662T	278	RC						Both			48.3	21.74	21.74	43.47		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	35.74							Fee Schedule																													43.47							Fee Schedule																																															
MICRO TUBING SET 60 INCH. 2N3358	272	RC						Both			3	1.35	1.35	2.7	1.95							Fee Schedule		2.22							Fee Schedule																													2.7							Fee Schedule																																															
MICROALBUMIN 24 HR UA 4555	301	RC	82043	CPT				Both			98.7	44.42	5.14	88.83	5.14							Fee Schedule		6.42							Fee Schedule		5.95							Fee Schedule		5.78							Fee Schedule											88.83							Fee Schedule																				5.78							Fee Schedule																				
MICROALBUMIN CREAT RATIO RANDOM UA 6517	301	RC	82043	CPT				Both			98.7	44.42	5.14	88.83	5.14							Fee Schedule		6.42							Fee Schedule		5.95							Fee Schedule		5.78							Fee Schedule		5.78							Fee Schedule		88.83							Fee Schedule		6.65							Fee Schedule		5.38							Fee Schedule		5.78							Fee Schedule		6.65							Fee Schedule		5.38							Fee Schedule		
MICROALBUMIN RANDOM QUEST 17674	301	RC	82043	CPT				Both			15	6.75	5.14	13.5	5.14							Fee Schedule		6.42							Fee Schedule		5.95							Fee Schedule		5.78							Fee Schedule		5.78							Fee Schedule		13.5							Fee Schedule		6.65							Fee Schedule		5.38							Fee Schedule		5.78							Fee Schedule		6.65							Fee Schedule		5.38							Fee Schedule		
MICROALBUMIN RANDOM URINE	301	RC	82043	CPT				Both			90.3	40.64	5.14	81.27	5.14							Fee Schedule		6.42							Fee Schedule		5.95							Fee Schedule		5.78							Fee Schedule		5.78							Fee Schedule		81.27							Fee Schedule		6.65							Fee Schedule		5.38							Fee Schedule		5.78							Fee Schedule		6.65							Fee Schedule		5.38							Fee Schedule		
MICROBLATOR 1.4MM #AC4050-01	272	RC						Both			928.2	417.69	5.38	835.38	603.33							Fee Schedule		686.87							Fee Schedule																				5.78							Fee Schedule		835.38							Fee Schedule		6.65							Fee Schedule		5.38							Fee Schedule											6.65							Fee Schedule		5.38							Fee Schedule		
MICROBRUSHES	272	RC						Both			71.4	32.13	32.13	64.26	46.41							Fee Schedule		52.84							Fee Schedule																													64.26							Fee Schedule																																															
MICROFOAM 4  #1528-4	270	RC						Both			10	4.5	4.5	9	6.5							Fee Schedule		7.4							Fee Schedule																													9							Fee Schedule																																															
"MICROSCOPE DRAPE #4820-90 (MTI ,INC.)"	272	RC						Both			28.35	12.76	12.76	25.52	18.43							Fee Schedule		20.98							Fee Schedule																													25.52							Fee Schedule																																															
MICROSCOPIC GENETIC EXAM MANUAL	310	RC	88377	CPT				Both			971.25	437.06	227.27	874.13	227.27							Fee Schedule		294.24							Fee Schedule											293.34							Fee Schedule											874.13							Fee Schedule																																															
MICROSOM AB LIVER KIDNEY 15038 SER	302	RC	86376	CPT				Both			187.95	84.58	12.93	169.16	12.93							Fee Schedule		16.17							Fee Schedule		14.99							Fee Schedule		14.55							Fee Schedule											169.16							Fee Schedule																				14.55							Fee Schedule																				
MICROSOM AB THYROID 5081	302	RC	86376	CPT				Both			85.05	38.27	12.93	76.55	12.93							Fee Schedule		16.17							Fee Schedule		14.99							Fee Schedule		14.55							Fee Schedule		14.55							Fee Schedule		76.55							Fee Schedule		16.73							Fee Schedule		13.53							Fee Schedule		14.55							Fee Schedule		16.73							Fee Schedule		13.53							Fee Schedule		
MICROSPORIDIA SPORE 3562 FECES IN FORM	310	RC	88313	CPT				Both			194.25	87.41	13.53	174.83	38.44							Fee Schedule		55.07							Fee Schedule											62.67							Fee Schedule		14.55							Fee Schedule		174.83							Fee Schedule		16.73							Fee Schedule		13.53							Fee Schedule											16.73							Fee Schedule		13.53							Fee Schedule		
MICROTEK CAMERA DRAPE #9904	272	RC						Both			18	8.1	8.1	16.2	11.7							Fee Schedule		13.32							Fee Schedule																													16.2							Fee Schedule																																															
MICROTEK MICROSOPE DRAPE #4821	272	RC						Both			28.35	12.76	12.76	25.52	18.43							Fee Schedule		20.98							Fee Schedule																													25.52							Fee Schedule																																															
MICROV BUTTON 3.4CM 24FR. M00562840	272	RC						Both			372.75	167.74	167.74	335.48	242.29							Fee Schedule		275.84							Fee Schedule																													335.48							Fee Schedule																																															
MICROV. G-TUBE REPLACEMENT 16 FR. 8206	272	RC						Both			242.55	109.15	109.15	218.3	157.66							Fee Schedule		179.49							Fee Schedule																													218.3							Fee Schedule																																															
MICROV. POLYFLEX STENT #M00514270	278	RC	C1874	CPT				Both			6300	2835	2835	5670		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	4662							Fee Schedule																													5670							Fee Schedule																																															
MICROV. WALL FLEX BILIARY STENT #7051	278	RC	C1877	CPT				Both			8961.75	4032.79	4032.79	8065.58		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	6631.7							Fee Schedule																													8065.58							Fee Schedule																																															
MICROV. WALL FLEX BILIARY STENT #7053	278	RC	C1875	CPT				Both			8961.75	4032.79	4032.79	8065.58		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	6631.7							Fee Schedule																													8065.58							Fee Schedule																																															
MICROV.18 FR. G-TUBE #6671 REPLACES 228	272	RC						Both			393.75	177.19	177.19	354.38	255.94							Fee Schedule		291.38							Fee Schedule																													354.38							Fee Schedule																																															
MICROV.ACHALASHIA DILATOR 30MM #5310	272	RC						Both			2134.65	960.59	960.59	1921.19	1387.52							Fee Schedule		1579.64							Fee Schedule																													1921.19							Fee Schedule																																															
MICROV.ACHALASHIA DILATOR 35MM #5311	272	RC						Both			2134.65	960.59	960.59	1921.19	1387.52							Fee Schedule		1579.64							Fee Schedule																													1921.19							Fee Schedule																																															
MICROV.ACHALASHIA DILATOR 40MM #5312	272	RC						Both			2134.65	960.59	960.59	1921.19	1387.52							Fee Schedule		1579.64							Fee Schedule																													1921.19							Fee Schedule																																															
MICROV.HAND PUMP AND MONITOR #5320	272	RC						Both			674.1	303.35	303.35	606.69	438.17							Fee Schedule		498.83							Fee Schedule																													606.69							Fee Schedule																																															
MICROV.LOW PROF. BUTTON REPL.#6283	272	RC						Both			449.4	202.23	202.23	404.46	292.11							Fee Schedule		332.56							Fee Schedule																													404.46							Fee Schedule																																															
MICROV.PERCAF.BILIARY STENT #3366	278	RC	C1877	CPT				Both			258.3	116.24	116.24	232.47		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	191.14							Fee Schedule																													232.47							Fee Schedule																																															
MICROV.PERCAF.BILIARY STENT #3367	278	RC	C1877	CPT				Both			220.5	99.23	99.23	198.45		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	163.17							Fee Schedule																													198.45							Fee Schedule																																															
MICROV.PERCAF.BILIARY STENT #3368	278	RC	C1877	CPT				Both			169.05	76.07	76.07	152.15		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	125.1							Fee Schedule																													152.15							Fee Schedule																																															
MICROV.PERCAF.BILIARY STENT #3369	278	RC	C1877	CPT				Both			236.25	106.31	106.31	212.63		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	174.83							Fee Schedule																													212.63							Fee Schedule																																															
MICROV.POLYFLEX 18X21X90 #1430	278	RC	C1874	CPT				Both			6741	3033.45	3033.45	6066.9		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	4988.34							Fee Schedule																													6066.9							Fee Schedule																																															
MICROV.POLYFLEX 21X25X90 #1433	278	RC	C1874	CPT				Both			6237	2806.65	2806.65	5613.3		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	4615.38							Fee Schedule																													5613.3							Fee Schedule																																															
MICROV.URETERAL STENT 190-122	278	RC	C2625	CPT				Both			551.25	248.06	248.06	496.13		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	407.93							Fee Schedule																													496.13							Fee Schedule																																															
MICROV18MM ESOPHOGEAL STENT M00519700	278	RC	C1874	CPT				Both			7500	3375	3375	6750		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	5550							Fee Schedule																													6750							Fee Schedule																																															
MICROVAS.CLEAR INJ. THERAP.NEEDLE #1145	272	RC						Both			185.85	83.63	83.63	167.27	120.8							Fee Schedule		137.53							Fee Schedule																													167.27							Fee Schedule																																															
MICROVASIVE 12FR SHEATH M00115718B1	272	RC	C1894	CPT				Both			31.5	14.18	14.18	87.34	87.34							Fee Schedule		23.31							Fee Schedule																													28.35							Fee Schedule																																															
MICROVASIVE 12FR SHEATH M00115728B1	272	RC	C1894	CPT				Both			34.65	15.59	15.59	87.34	87.34							Fee Schedule		25.64							Fee Schedule																													31.19							Fee Schedule																																															
MICROVASIVE 14FR SHEATH M00115741B1	272	RC	C1894	CPT				Both			31.5	14.18	14.18	87.34	87.34							Fee Schedule		23.31							Fee Schedule																													28.35							Fee Schedule																																															
MICROVASIVE 16 FR. G TUBE	270	RC	B4087	CPT				Both			87.15	39.22	14.31	78.44	14.31							Fee Schedule		64.49							Fee Schedule																													78.44							Fee Schedule																																															
MICROVASIVE 18 FR. G TUBE #6218 *DISC.*	270	RC						Both			115.5	51.98	51.98	103.95	75.08							Fee Schedule		85.47							Fee Schedule																													103.95							Fee Schedule																																															
MICROVASIVE 18 FR. REPL. G TUBE #8207	270	RC	B4087	CPT				Both			108.15	48.67	14.31	97.34	14.31							Fee Schedule		80.03							Fee Schedule																													97.34							Fee Schedule																																															
MICROVASIVE 18 FR.BOLUS ADAPT.#8017	272	RC						Both			28.35	12.76	12.76	25.52	18.43							Fee Schedule		20.98							Fee Schedule																													25.52							Fee Schedule																																															
MICROVASIVE 18FR.BALLOON 6351	272	RC						Both			337.05	151.67	151.67	303.35	219.08							Fee Schedule		249.42							Fee Schedule																													303.35							Fee Schedule																																															
MICROVASIVE 18FR.BALLOON REPLAC.#6352	272	RC	B4087	CPT				Both			337.05	151.67	14.31	303.35	14.31							Fee Schedule		249.42							Fee Schedule																													303.35							Fee Schedule																																															
MICROVASIVE 20 FR. REPL. G TUBE #8208	270	RC	B4087	CPT				Both			306	137.7	14.31	275.4	14.31							Fee Schedule		226.44							Fee Schedule																													275.4							Fee Schedule																																															
MICROVASIVE 20FR G TUBE M00509411	270	RC	B4087	CPT				Both			319	143.55	14.31	287.1	14.31							Fee Schedule		236.06							Fee Schedule																													287.1							Fee Schedule																																															
MICROVASIVE 24 FR. G TUBE #6224	272	RC	B4087	CPT				Both			306	137.7	14.31	275.4	14.31							Fee Schedule		226.44							Fee Schedule																													275.4							Fee Schedule																																															
MICROVASIVE 24FR G TUBE M00509441	270	RC	B4087	CPT				Both			319	143.55	14.31	287.1	14.31							Fee Schedule		236.06							Fee Schedule																													287.1							Fee Schedule																																															
MICROVASIVE 60 ML SYR.ASSEMBLY#5060-05	272	RC						Both			100	45	45	90	65							Fee Schedule		74							Fee Schedule																													90							Fee Schedule																																															
MICROVASIVE CAPIO SUTURE CAPT.DEVICE	272	RC	C2631	CPT				Both			1517.25	682.76	682.76	1365.53	846.59							Fee Schedule		1122.77							Fee Schedule																													1365.53							Fee Schedule																																															
MICROVASIVE CAPTIFLEX MINI OVAL	272	RC						Both			79.8	35.91	35.91	71.82	51.87							Fee Schedule		59.05							Fee Schedule																													71.82							Fee Schedule																																															
MICROVASIVE CATHETER H74939171120470	278	RC	C1725	CPT				Both			447.3	201.29	201.29	402.57		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	331							Fee Schedule																													402.57							Fee Schedule																																															
MICROVASIVE CRESCENT POLYP SNARE#6237	272	RC						Both			126	56.7	56.7	113.4	81.9							Fee Schedule		93.24							Fee Schedule																													113.4							Fee Schedule																																															
MICROVASIVE CTO DEVICE 3920818165	272	RC	C1769	CPT				Both			6573	2957.85	154.26	5915.7	154.26							Fee Schedule		4864.02							Fee Schedule																													5915.7							Fee Schedule																																															
MICROVASIVE DILATOR CATH M00550601	272	RC						Both			100	45	45	90	65							Fee Schedule		74							Fee Schedule																													90							Fee Schedule																																															
MICROVASIVE ESOPH.STENT PROX. #1412	278	RC	C1874	CPT				Both			4027.8	1812.51	1812.51	3625.02		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	2980.57							Fee Schedule																													3625.02							Fee Schedule																																															
MICROVASIVE ESOPHAGEAL STENT 1310	278	RC	C1876	CPT				Both			4297.65	1933.94	1933.94	3867.89		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	3180.26							Fee Schedule																													3867.89							Fee Schedule																																															
MICROVASIVE ESOPHAGEAL STENT 1465	278	RC	C1876	CPT				Both			4634.7	2085.62	2085.62	4171.23		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	3429.68							Fee Schedule																													4171.23							Fee Schedule																																															
MICROVASIVE ESOPHAGEAL STENT 1465	278	RC	C1876	CPT				Both			4634.7	2085.62	2085.62	4171.23		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	3429.68							Fee Schedule																													4171.23							Fee Schedule																																															
MICROVASIVE ESOPHAGEAL STENT M00517450	278	RC	C1876	CPT				Both			9182	4131.9	4131.9	8263.8		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	6794.68							Fee Schedule																													8263.8							Fee Schedule																																															
MICROVASIVE FEEDING BALLOON 20FR 5622	272	RC						Both			113.4	51.03	51.03	102.06	73.71							Fee Schedule		83.92							Fee Schedule																													102.06							Fee Schedule																																															
MICROVASIVE GUIDE WIRE 630-222B	272	RC	C1769	CPT				Both			173.25	77.96	77.96	155.93	154.26							Fee Schedule		128.21							Fee Schedule																													155.93							Fee Schedule																																															
MICROVASIVE HERCULES 5863   12-13.5-15	272	RC	C1726	CPT				Both			668	300.6	135.94	601.2	135.94							Fee Schedule		494.32							Fee Schedule																													601.2							Fee Schedule																																															
MICROVASIVE HERCULES 5864 15-16.5-18	272	RC	C1726	CPT				Both			668	300.6	135.94	601.2	135.94							Fee Schedule		494.32							Fee Schedule																													601.2							Fee Schedule																																															
MICROVASIVE HERCULES 5865  18-19-20	272	RC	C1726	CPT				Both			668	300.6	135.94	601.2	135.94							Fee Schedule		494.32							Fee Schedule																													601.2							Fee Schedule																																															
MICROVASIVE HYDRA JAGWIRE 5604	272	RC	C1769	CPT				Both			586.16	263.77	154.26	527.54	154.26							Fee Schedule		433.76							Fee Schedule																													527.54							Fee Schedule																																															
MICROVASIVE INFLATION DEVICE M001151050	272	RC						Both			75	33.75	33.75	67.5	48.75							Fee Schedule		55.5							Fee Schedule																													67.5							Fee Schedule																																															
MICROVASIVE INFLATION DEVICE M001151062	272	RC						Both			275.1	123.8	123.8	247.59	178.82							Fee Schedule		203.57							Fee Schedule																													247.59							Fee Schedule																																															
MICROVASIVE INFLATION DIVICE M001151062	272	RC						Both			110.25	49.61	49.61	99.23	71.66							Fee Schedule		81.59							Fee Schedule																													99.23							Fee Schedule																																															
MICROVASIVE INFLATION DIVICE M00550620	272	RC						Both			1350	607.5	607.5	1215	877.5							Fee Schedule		999							Fee Schedule																													1215							Fee Schedule																																															
MICROVASIVE JAGWIRE  5658	272	RC	C1769	CPT				Both			707	318.15	154.26	636.3	154.26							Fee Schedule		523.18							Fee Schedule																													636.3							Fee Schedule																																															
MICROVASIVE JAW BX. FORCEP #1599	272	RC						Both			105	47.25	47.25	94.5	68.25							Fee Schedule		77.7							Fee Schedule																													94.5							Fee Schedule																																															
MICROVASIVE JEJUNAL FEEDING TUBE 6634	270	RC						Both			795	357.75	357.75	715.5	516.75							Fee Schedule		588.3							Fee Schedule																													715.5							Fee Schedule																																															
MICROVASIVE KNIFE XL#3281	272	RC						Both			437	196.65	196.65	393.3	284.05							Fee Schedule		323.38							Fee Schedule																													393.3							Fee Schedule																																															
MICROVASIVE LG OVAL SNARE M00562651	272	RC						Both			57	25.65	25.65	51.3	37.05							Fee Schedule		42.18							Fee Schedule																													51.3							Fee Schedule																																															
MICROVASIVE LG. OVAL POLP.SNARE#6131	272	RC						Both			115.5	51.98	51.98	103.95	75.08							Fee Schedule		85.47							Fee Schedule																													103.95							Fee Schedule																																															
MICROVASIVE LIGATORS SPEEDBAND M00542253	278	RC	C1769	CPT				Both			1826	821.7	821.7	1643.4		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1351.24							Fee Schedule																													1643.4							Fee Schedule																																															
MICROVASIVE LITHOTRIPT BASKET #1088	272	RC						Both			1123.5	505.58	505.58	1011.15	730.28							Fee Schedule		831.39							Fee Schedule																													1011.15							Fee Schedule																																															
MICROVASIVE LOCKING DEVICE CAP M00545281	272	RC						Both			371	166.95	166.95	333.9	241.15							Fee Schedule		274.54							Fee Schedule																													333.9							Fee Schedule																																															
MICROVASIVE MANTIS CLIP M00521420	272	RC						Both			1215	546.75	546.75	1093.5	789.75							Fee Schedule		899.1							Fee Schedule																													1093.5							Fee Schedule																																															
MICROVASIVE MED OVAL SNARE M00562673	272	RC						Both			28	12.6	12.6	25.2	18.2							Fee Schedule		20.72							Fee Schedule																													25.2							Fee Schedule																																															
MICROVASIVE MONLITHOTRYPT #1087	272	RC						Both			1123.5	505.58	505.58	1011.15	730.28							Fee Schedule		831.39							Fee Schedule																													1011.15							Fee Schedule																																															
MICROVASIVE OBTRYX URETHRAL SLING	272	RC	C1771	CPT				Both			4754.14	2139.36	87.91	4278.73	87.91							Fee Schedule		3518.06							Fee Schedule																													4278.73							Fee Schedule																																															
MICROVASIVE POSITRAP #1061	272	RC						Both			449.4	202.23	202.23	404.46	292.11							Fee Schedule		332.56							Fee Schedule																													404.46							Fee Schedule																																															
MICROVASIVE RADIAL JAW 1550	272	RC						Both			160.65	72.29	72.29	144.59	104.42							Fee Schedule		118.88							Fee Schedule																													144.59							Fee Schedule																																															
MICROVASIVE RADIAL JAW M00513332	272	RC						Both			10	4.5	4.5	9	6.5							Fee Schedule		7.4							Fee Schedule																													9							Fee Schedule																																															
MICROVASIVE RATTOOTH M00538351	272	RC						Both			265	119.25	119.25	238.5	172.25							Fee Schedule		196.1							Fee Schedule																													238.5							Fee Schedule																																															
MICROVASIVE RENAL GUIDE CATH M001197960	272	RC	C1887	CPT				Both			296.36	133.36	43.86	266.72	43.86							Fee Schedule		219.31							Fee Schedule																													266.72							Fee Schedule																																															
MICROVASIVE RENEGADE CATH   M001181310	272	RC	C1887	CPT				Both			1369.2	616.14	43.86	1232.28	43.86							Fee Schedule		1013.21							Fee Schedule																													1232.28							Fee Schedule																																															
MICROVASIVE REPL. G-TUBE #M00582080	270	RC	B4087	CPT				Both			306	137.7	14.31	275.4	14.31							Fee Schedule		226.44							Fee Schedule																													275.4							Fee Schedule																																															
MICROVASIVE RESOLUTION CLIP M00521402	278	RC	C1769	CPT				Both			704	316.8	316.8	633.6		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	520.96							Fee Schedule																													633.6							Fee Schedule																																															
MICROVASIVE RETRIEVAL NET  DGN-538-5	272	RC						Both			273	122.85	122.85	245.7	177.45							Fee Schedule		202.02							Fee Schedule																													245.7							Fee Schedule																																															
MICROVASIVE SCOPE KIT #CEK-1800-20	272	RC						Both			53	23.85	23.85	47.7	34.45							Fee Schedule		39.22							Fee Schedule																													47.7							Fee Schedule																																															
MICROVASIVE SCOPE KIT #CEK-1876-20	272	RC						Both			52	23.4	23.4	46.8	33.8							Fee Schedule		38.48							Fee Schedule																													46.8							Fee Schedule																																															
MICROVASIVE SET UP PAK CEK-788-20	272	RC						Both			48	21.6	21.6	43.2	31.2							Fee Schedule		35.52							Fee Schedule																													43.2							Fee Schedule																																															
MICROVASIVE SET UP PAK CEK-876-20	272	RC						Both			46	20.7	20.7	41.4	29.9							Fee Schedule		34.04							Fee Schedule																													41.4							Fee Schedule																																															
MICROVASIVE SMALL OVAL SNARE 6242	272	RC						Both			44.1	19.85	19.85	39.69	28.67							Fee Schedule		32.63							Fee Schedule																													39.69							Fee Schedule																																															
MICROVASIVE SMALL OVAL SNARE M00562693	272	RC						Both			28	12.6	12.6	25.2	18.2							Fee Schedule		20.72							Fee Schedule																													25.2							Fee Schedule																																															
MICROVASIVE SNARE #6245	272	RC						Both			43	19.35	19.35	38.7	27.95							Fee Schedule		31.82							Fee Schedule																													38.7							Fee Schedule																																															
MICROVASIVE SPEEDBAND #4225	272	RC						Both			456	205.2	205.2	410.4	296.4							Fee Schedule		337.44							Fee Schedule																													410.4							Fee Schedule																																															
MICROVASIVE SPEEDBAND SUPER 7 #M00542250	278	RC	C1769	CPT				Both			895.65	403.04	403.04	806.09		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	662.78							Fee Schedule																													806.09							Fee Schedule																																															
MICROVASIVE SPYGLASS BASKET M00546550	272	RC						Both			1610	724.5	724.5	1449	1046.5							Fee Schedule		1191.4							Fee Schedule																													1449							Fee Schedule																																															
MICROVASIVE SPYGLASS SNARE M00546560	272	RC						Both			1610	724.5	724.5	1449	1046.5							Fee Schedule		1191.4							Fee Schedule																													1449							Fee Schedule																																															
MICROVASIVE STENT 513850	278	RC	C1874	CPT				Both			5407.5	2433.38	2433.38	4866.75		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	4001.55							Fee Schedule																													4866.75							Fee Schedule																																															
MICROVASIVE STENT H74937911515900	278	RC	C1876	CPT				Both			2205	992.25	992.25	1984.5		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1631.7							Fee Schedule																													1984.5							Fee Schedule																																															
MICROVASIVE STENT H74939171050410	278	RC	C1876	CPT				Both			447.3	201.29	201.29	402.57		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	331							Fee Schedule																													402.57							Fee Schedule																																															
MICROVASIVE STENT H74939171052010	278	RC	C1876	CPT				Both			493.5	222.08	222.08	444.15		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	365.19							Fee Schedule																													444.15							Fee Schedule																																															
MICROVASIVE STENT H74939293051030	278	RC	C1876	CPT				Both			2205	992.25	992.25	1984.5		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1631.7							Fee Schedule																													1984.5							Fee Schedule																																															
MICROVASIVE STENT H74939293061030	278	RC	C1876	CPT				Both			2205	992.25	992.25	1984.5		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1631.7							Fee Schedule																													1984.5							Fee Schedule																																															
MICROVASIVE STENT H74939293061230	278	RC	C1876	CPT				Both			2205	992.25	992.25	1984.5		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1631.7							Fee Schedule																													1984.5							Fee Schedule																																															
MICROVASIVE STENT H74939293061530	278	RC	C1876	CPT				Both			2205	992.25	992.25	1984.5		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1631.7							Fee Schedule																													1984.5							Fee Schedule																																															
MICROVASIVE STENT H74939293064030	278	RC	C1876	CPT				Both			2205	992.25	992.25	1984.5		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1631.7							Fee Schedule																													1984.5							Fee Schedule																																															
MICROVASIVE STENT H74939293066030	278	RC	C1876	CPT				Both			2205	992.25	992.25	1984.5		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1631.7							Fee Schedule																													1984.5							Fee Schedule																																															
MICROVASIVE STENT H74939293068030	278	RC	C1876	CPT				Both			2205	992.25	992.25	1984.5		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1631.7							Fee Schedule																													1984.5							Fee Schedule																																															
MICROVASIVE STENT H74939293071030	278	RC	C1876	CPT				Both			2205	992.25	992.25	1984.5		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1631.7							Fee Schedule																													1984.5							Fee Schedule																																															
MICROVASIVE STENT H74939293074030	278	RC	C1876	CPT				Both			2205	992.25	992.25	1984.5		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1631.7							Fee Schedule																													1984.5							Fee Schedule																																															
MICROVASIVE STENT H74939293076030	278	RC	C1876	CPT				Both			2205	992.25	992.25	1984.5		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1631.7							Fee Schedule																													1984.5							Fee Schedule																																															
MICROVASIVE STENT H74939293078030	278	RC	C1876	CPT				Both			2205	992.25	992.25	1984.5		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1631.7							Fee Schedule																													1984.5							Fee Schedule																																															
MICROVASIVE STENT M00516700	278	RC	C1874	CPT				Both			7518	3383.1	3383.1	6766.2		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	5563.32							Fee Schedule																													6766.2							Fee Schedule																																															
MICROVASIVE SUTURE TAPER #M0068332241	272	RC	C2631	CPT				Both			158	71.1	71.1	846.59	846.59							Fee Schedule		116.92							Fee Schedule																													142.2							Fee Schedule																																															
MICROVASIVE TRAPEASE STE-298-25	272	RC						Both			10	4.5	4.5	9	6.5							Fee Schedule		7.4							Fee Schedule																													9							Fee Schedule																																															
MICROVASIVE TRAPEZOID BASKET M00510890	272	RC						Both			875	393.75	393.75	787.5	568.75							Fee Schedule		647.5							Fee Schedule																													787.5							Fee Schedule																																															
MICROVASIVE TRAPEZOID RX	272	RC						Both			940.8	423.36	423.36	846.72	611.52							Fee Schedule		696.19							Fee Schedule																													846.72							Fee Schedule																																															
MICROVASIVE TWISTER 13MM #M00561401	272	RC						Both			236.25	106.31	106.31	212.63	153.56							Fee Schedule		174.83							Fee Schedule																													212.63							Fee Schedule																																															
MICROVASIVE TWISTER 22MM #M00561411	272	RC						Both			236.25	106.31	106.31	212.63	153.56							Fee Schedule		174.83							Fee Schedule																													212.63							Fee Schedule																																															
MICROVASIVE TWISTER 25MM #M00561421	272	RC						Both			236.25	106.31	106.31	212.63	153.56							Fee Schedule		174.83							Fee Schedule																													212.63							Fee Schedule																																															
MICROVASIVE ULTRATOME XL 3 LUMEN 3590	272	RC						Both			573.3	257.99	257.99	515.97	372.65							Fee Schedule		424.24							Fee Schedule																													515.97							Fee Schedule																																															
MICROVASIVE ULTRATOME XL 3 LUMEN 3592	272	RC						Both			573.3	257.99	257.99	515.97	372.65							Fee Schedule		424.24							Fee Schedule																													515.97							Fee Schedule																																															
MICROVASIVE VASC. STENT H74939293061230	278	RC	C1876	CPT				Both			296.36	133.36	133.36	266.72		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	219.31							Fee Schedule																													266.72							Fee Schedule																																															
MICROVASIVE WALL FLEX #6511	278	RC	C1877	CPT				Both			7859.25	3536.66	3536.66	7073.33		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	5815.85							Fee Schedule																													7073.33							Fee Schedule																																															
MICROVASIVE WALL FLEX GUIDE WIRE #18001	272	RC	C1769	CPT				Both			2028.6	912.87	154.26	1825.74	154.26							Fee Schedule		1501.16							Fee Schedule																													1825.74							Fee Schedule																																															
MICROVASIVE WALL STENT 8X60 #6962	272	RC						Both			4494	2022.3	2022.3	4044.6	2921.1							Fee Schedule		3325.56							Fee Schedule																													4044.6							Fee Schedule																																															
MICROVASIVE WALLSTENT 10X80 #43120	278	RC	C1874	CPT				Both			5022.15	2259.97	2259.97	4519.94		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	3716.39							Fee Schedule																													4519.94							Fee Schedule																																															
MICROVASIVE ZEBRA EXCHANGE WIRE 5168	272	RC	C1769	CPT				Both			366.45	164.9	154.26	329.81	154.26							Fee Schedule		271.17							Fee Schedule																													329.81							Fee Schedule																																															
MIDAMOR TABLETS	250	RC	A9270	CPT				Both			1.58	0.71	0.01	1.42	0.01							Fee Schedule		1.17							Fee Schedule																													1.42							Fee Schedule																																															
MIDAZOLAM 1 MG/ML-10ML MDV- PER ML	636	RC	J2250	CPT				Both			12.6	5.67	0.15	11.34		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	9.32							Fee Schedule		0.15							Fee Schedule		2.87							Fee Schedule											11.34							Fee Schedule																																															
MIDAZOLAM 100MG/NS 100ML IVPB	636	RC	J2250	CPT				Both			73.5	33.08	0.13	66.15		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	54.39							Fee Schedule		0.15							Fee Schedule		2.87							Fee Schedule		0.14							Fee Schedule		66.15							Fee Schedule		0.16							Fee Schedule		0.13							Fee Schedule											0.16							Fee Schedule		0.13							Fee Schedule		
MIDAZOLAM 100MG/NS 100ML PREMIX	636	RC	J2251	CPT				Both			107.97	48.59	0.12	97.17		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	79.9							Fee Schedule		0.12							Fee Schedule											0.14							Fee Schedule		97.17							Fee Schedule		0.16							Fee Schedule		0.13							Fee Schedule											0.16							Fee Schedule		0.13							Fee Schedule		
MIDAZOLAM 10MG/2ML INJ-FOR ATOMIZER ONLY	636	RC	J2250	CPT				Both			4.89	2.2	0.11	4.4		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	3.62							Fee Schedule		0.15							Fee Schedule		2.87							Fee Schedule		0.12							Fee Schedule		4.4							Fee Schedule		0.13							Fee Schedule		0.11							Fee Schedule											0.13							Fee Schedule		0.11							Fee Schedule		
MIDAZOLAM 2 MG/ML (VERSED) ORAL SYRUP	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																				0.14							Fee Schedule		5.67							Fee Schedule		0.16							Fee Schedule		0.13							Fee Schedule											0.16							Fee Schedule		0.13							Fee Schedule		
MIDAZOLAM 2MG/2ML (VERSED) INJ	636	RC	J2250	CPT				Both			12.6	5.67	0.15	11.34		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	9.32							Fee Schedule		0.15							Fee Schedule		2.87							Fee Schedule											11.34							Fee Schedule																																															
MIDAZOLAM 5 MG/ML-10 ML VIAL:BILL BY ML	636	RC	J2250	CPT				Both			12.6	5.67	0.13	11.34		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	9.32							Fee Schedule		0.15							Fee Schedule		2.87							Fee Schedule		0.14							Fee Schedule		11.34							Fee Schedule		0.16							Fee Schedule		0.13							Fee Schedule											0.16							Fee Schedule		0.13							Fee Schedule		
MIDAZOLAM 50MG/NS 50ML PREMIX	636	RC	J2250	CPT				Both			79.17	35.63	0.13	71.25		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	58.59							Fee Schedule		0.15							Fee Schedule		2.87							Fee Schedule		0.14							Fee Schedule		71.25							Fee Schedule		0.16							Fee Schedule		0.13							Fee Schedule											0.16							Fee Schedule		0.13							Fee Schedule		
MIDAZOLAM 5MG/2.5ML(VERSED) ORAL SYRUP	250	RC	A9270	CPT				Both			15.75	7.09	0.01	14.18	0.01							Fee Schedule		11.66							Fee Schedule																				0.14							Fee Schedule		14.18							Fee Schedule		0.16							Fee Schedule		0.13							Fee Schedule											0.16							Fee Schedule		0.13							Fee Schedule		
MIDAZOLAM 5MG/5ML (VERSED) INJ	636	RC	J2250	CPT				Both			12	5.4	0.15	10.8		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	8.88							Fee Schedule		0.15							Fee Schedule		2.87							Fee Schedule											10.8							Fee Schedule																																															
MIDAZOLAM HCL 5  MG/ML- 2ML (VERSED) INJ	636	RC	J2250	CPT				Both			12.6	5.67	0.13	11.34		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	9.32							Fee Schedule		0.15							Fee Schedule		2.87							Fee Schedule		0.14							Fee Schedule		11.34							Fee Schedule		0.16							Fee Schedule		0.13							Fee Schedule											0.16							Fee Schedule		0.13							Fee Schedule		
MIDAZOLAM HCL 50 MG/10ML INJECTION	636	RC	J2250	CPT				Both			12.6	5.67	0.13	11.34		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	9.32							Fee Schedule		0.15							Fee Schedule		2.87							Fee Schedule		0.14							Fee Schedule		11.34							Fee Schedule		0.16							Fee Schedule		0.13							Fee Schedule											0.16							Fee Schedule		0.13							Fee Schedule		
MIDLINE CATH POWERGLIDE 18GX8CM F118080T	272	RC	C1751	CPT				Both			207	93.15	0.13	186.3	69.11							Fee Schedule		153.18							Fee Schedule																				0.14							Fee Schedule		186.3							Fee Schedule		0.16							Fee Schedule		0.13							Fee Schedule											0.16							Fee Schedule		0.13							Fee Schedule		
MIDLINE CATH POWERGLIDE 18X10CM F118100T	272	RC	C1751	CPT				Both			207	93.15	69.11	186.3	69.11							Fee Schedule		153.18							Fee Schedule																													186.3							Fee Schedule																																															
MIDLINE CATH POWERGLIDE 20GX8CM F120080T	272	RC	C1751	CPT				Both			207	93.15	69.11	186.3	69.11							Fee Schedule		153.18							Fee Schedule																													186.3							Fee Schedule																																															
MIDLINE CATH POWERGLIDE 20X10CM F120100T	272	RC	C1751	CPT				Both			207	93.15	69.11	186.3	69.11							Fee Schedule		153.18							Fee Schedule																													186.3							Fee Schedule																																															
MIDLINE PWR DUAL MAX KIT 4 FR. P4254108D	272	RC	C1751	CPT				Both			521.85	234.83	69.11	469.67	69.11							Fee Schedule		386.17							Fee Schedule																													469.67							Fee Schedule																																															
MIDODRINE 2.5 MG (PROAMATINE) TABLET	250	RC	A9270	CPT				Both			9.45	4.25	0.01	8.51	0.01							Fee Schedule		6.99							Fee Schedule																													8.51							Fee Schedule																																															
MIDRIN CAP CARNRICK	250	RC	A9270	CPT				Both			1.58	0.71	0.01	1.42	0.01							Fee Schedule		1.17							Fee Schedule																													1.42							Fee Schedule																																															
MIGQUIN CAPSULE UD	250	RC	A9270	CPT				Both			5.25	2.36	0.01	4.73	0.01							Fee Schedule		3.89							Fee Schedule																													4.73							Fee Schedule																																															
MILK OF MAGNESIA 30ML	250	RC						Both			4.2	1.89	1.89	3.78	2.73							Fee Schedule		3.11							Fee Schedule																													3.78							Fee Schedule																																															
MILK OF MAGNESIA SUSPENSION 30ML UD	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
MILKINOL:PER OZ	250	RC	A9270	CPT				Both			4.2	1.89	0.01	3.78	0.01							Fee Schedule		3.11							Fee Schedule																													3.78							Fee Schedule																																															
MILRINONE 10 MG/10 ML (PRIMACOR) VIAL	636	RC	J2260	CPT				Both			324.45	146	1.13	292.01		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	240.09							Fee Schedule		1.13							Fee Schedule		39.42							Fee Schedule											292.01							Fee Schedule																																															
MILRINONE 20MG/100ML (PRIMACOR) PREMIX	636	RC	J2260	CPT				Both			82.95	37.33	1.02	74.66		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	61.38							Fee Schedule		1.13							Fee Schedule		39.42							Fee Schedule		1.1							Fee Schedule		74.66							Fee Schedule		1.26							Fee Schedule		1.02							Fee Schedule											1.26							Fee Schedule		1.02							Fee Schedule		
MINERAL OIL  473ML BOTTLE	250	RC						Both			15.44	6.95	1.02	13.9	10.04							Fee Schedule		11.43							Fee Schedule																				1.1							Fee Schedule		13.9							Fee Schedule		1.26							Fee Schedule		1.02							Fee Schedule											1.26							Fee Schedule		1.02							Fee Schedule		
MINERAL OIL 30 ML UD	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
MINERAL OIL 30CC	250	RC						Both			1.26	0.57	0.57	1.13	0.82							Fee Schedule		0.93							Fee Schedule																													1.13							Fee Schedule																																															
MINERAL OIL LIGHT 10 ML SDV	250	RC						Both			5.25	2.36	2.36	4.73	3.41							Fee Schedule		3.89							Fee Schedule																													4.73							Fee Schedule																																															
MINI SPIKE SET 412012	272	RC						Both			3.15	1.42	1.42	2.84	2.05							Fee Schedule		2.33							Fee Schedule																													2.84							Fee Schedule																																															
MINILAP SYSTEM ALLIGATOR GRASPER PGAC300	270	RC						Both			719	323.55	323.55	647.1	467.35							Fee Schedule		532.06							Fee Schedule																													647.1							Fee Schedule																																															
MINIONE BALLOON BUTTON M1-5-1227-I	272	RC						Both			396	178.2	178.2	356.4	257.4							Fee Schedule		293.04							Fee Schedule																													356.4							Fee Schedule																																															
MINIONE BALLOON BUTTON M1-5-1827-I	272	RC						Both			396	178.2	178.2	356.4	257.4							Fee Schedule		293.04							Fee Schedule																													356.4							Fee Schedule																																															
MINIONE BALLOON BUTTON M1-5-1860-I	272	RC						Both			441	198.45	198.45	396.9	286.65							Fee Schedule		326.34							Fee Schedule																													396.9							Fee Schedule																																															
MINIPRES 1 MG    (PRAZOSIN)	250	RC	A9270	CPT				Both			4.2	1.89	0.01	3.78	0.01							Fee Schedule		3.11							Fee Schedule																													3.78							Fee Schedule																																															
MINIVOLUME EXTENSION SET W/FILTER	272	RC						Both			11.55	5.2	5.2	10.4	7.51							Fee Schedule		8.55							Fee Schedule																													10.4							Fee Schedule																																															
MINOCIN 100 MG INJECTION	250	RC	A9270	CPT				Both			108.93	49.02	0.01	98.04	0.01							Fee Schedule		80.61							Fee Schedule																													98.04							Fee Schedule																																															
MINOR	360	RC						Both			3000	1350	1350	2700	1950							Fee Schedule		2220							Fee Schedule																													2700							Fee Schedule																																															
"SHOULDER, ELBOW OR FOREARM PROCEDURES, EXCEPT MAJOR JOINT PR"					511	DRG		Inpatient			60246.96	27111.13	27111.13	27111.13							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period	
"SHOULDER, ELBOW OR FOREARM PROCEDURES, EXCEPT MAJOR JOINT PR"					512	DRG		Inpatient			38921.34	17514.6	17514.6	17514.6							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period	
MINOXIDIL 10MG (LONITEN) TABLET	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
MIRALAX 17 GM POWDER PACKETS ORAL SOL	250	RC	A9270	CPT				Both			7.35	3.31	0.01	6.62	0.01							Fee Schedule		5.44							Fee Schedule																													6.62							Fee Schedule																																															
MIRALAX POWDER 17 GMS	250	RC	A9270	CPT				Both			4.2	1.89	0.01	3.78	0.01							Fee Schedule		3.11							Fee Schedule																													3.78							Fee Schedule																																															
MIRAPEX 0.125 MG TABS.	250	RC	A9270	CPT				Both			2.27	1.02	0.01	2.04	0.01							Fee Schedule		1.68							Fee Schedule																													2.04							Fee Schedule																																															
MIRTAZAPINE  7.5MG (REMERON) TABLET	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
MIRTAZAPINE 15MG (REMERON) TABLET	250	RC	A9270	CPT				Both			10.5	4.73	0.01	9.45	0.01							Fee Schedule		7.77							Fee Schedule																													9.45							Fee Schedule																																															
MIRTAZAPINE 30MG (REMERON) TABLET	250	RC	A9270	CPT				Both			10.5	4.73	0.01	9.45	0.01							Fee Schedule		7.77							Fee Schedule																													9.45							Fee Schedule																																															
MISC LAB	305	RC						Both			150.15	67.57	67.57	135.14	97.6							Fee Schedule		111.11							Fee Schedule																													135.14							Fee Schedule																																															
MISC PHARM ITEM	250	RC						Both			6.3	2.84	2.84	5.67	4.1							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
MISC PHARM ITEM	250	RC						Both			6.3	2.84	2.84	5.67	4.1							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
"HAND OR WRIST PROCEDURES, EXCEPT MAJOR THUMB OR JOINT PROCED"					513	DRG		Inpatient			20964.38	9433.97	9433.97	9433.97							0		No services performed during 15 month lookback period. 				4474.04	4474.04	4474.04	1 through 10						11948.16	11948.16	11948.16	1 through 10						4832.27	4832.27	4832.27	1 through 10									0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period	
"HAND OR WRIST PROCEDURES, EXCEPT MAJOR THUMB OR JOINT PROCED"					514	DRG		Inpatient			25822.12	11619.96	11619.96	11619.96							0		No services performed during 15 month lookback period. 				1144.12	1144.12	1144.12	1 through 10									0		No services performed during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period	
MISOPROSTOL  (CYTOTEC)  100 MCG  TABLET	250	RC	A9270	CPT				Both			8.4	3.78	0.01	7.56	0.01							Fee Schedule		6.22							Fee Schedule																													7.56							Fee Schedule																																															
MISOPROSTOL  (CYTOTEC)  200 MCG  TABLET	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
MITEK ANCHOR #212032 OLD#212032	278	RC	C1713	CPT				Both			820.05	369.02	369.02	738.05		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	606.84							Fee Schedule																													738.05							Fee Schedule																																															
MITEK COMISPHERE 228140	278	RC	C1713	CPT				Both			1203.3	541.49	541.49	1082.97		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	890.44							Fee Schedule																													1082.97							Fee Schedule																																															
MITEK COMISPHERE 228141	278	RC	C1713	CPT				Both			1203.3	541.49	541.49	1082.97		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	890.44							Fee Schedule																													1082.97							Fee Schedule																																															
MITEK COMISPHERE 228142	278	RC	C1713	CPT				Both			1146.6	515.97	515.97	1031.94		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	848.48							Fee Schedule																													1031.94							Fee Schedule																																															
MITEK FASTIN ANCHOR #222721	270	RC						Both			681.45	306.65	306.65	613.31	442.94							Fee Schedule		504.27							Fee Schedule																													613.31							Fee Schedule																																															
MITEK GII ANCHOR	278	RC	C1713	CPT				Both			535.5	240.98	240.98	481.95		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	396.27							Fee Schedule																													481.95							Fee Schedule																																															
MITEK GRAF KNIFE 10MM # 232110	272	RC						Both			974	438.3	438.3	876.6	633.1							Fee Schedule		720.76							Fee Schedule																													876.6							Fee Schedule																																															
MITEK GUN 228143	272	RC						Both			752.85	338.78	338.78	677.57	489.35							Fee Schedule		557.11							Fee Schedule																													677.57							Fee Schedule																																															
MITHRACIN IV:2500 MCG ONE USE VIAL	636	RC	J9270	CPT				Both			898.4	404.28	404.28	808.56		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	664.82							Fee Schedule																													808.56							Fee Schedule																																															
MITOCHONDRIAL ABS 259 SERUM	302	RC	86255	CPT				Both			55	24.75	10.71	49.5	10.71							Fee Schedule		13.39							Fee Schedule		12.41							Fee Schedule		12.05							Fee Schedule											49.5							Fee Schedule																				12.05							Fee Schedule																				
MITOMYCIN 40MG INJECTION	636	RC	J9280	CPT				Both			4459.35	2006.71	11.21	4013.42		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	28.46							Fee Schedule		26.89							Fee Schedule		164.59							Fee Schedule		12.05							Fee Schedule		4013.42							Fee Schedule		13.86							Fee Schedule		11.21							Fee Schedule											13.86							Fee Schedule		11.21							Fee Schedule		
MITRAFLEX DRSG EACH	272	RC						Both			15.75	7.09	7.09	30.02	10.24							Fee Schedule		11.66							Fee Schedule																				26.1							Fee Schedule		14.18							Fee Schedule		30.02							Fee Schedule		24.28							Fee Schedule											30.02							Fee Schedule		24.28							Fee Schedule		
MITROFLEX 8X8	272	RC						Both			68.51	30.83	30.83	61.66	44.53							Fee Schedule		50.7							Fee Schedule																													61.66							Fee Schedule																																															
MITTS HAND CONTROL NEW#79-91220	274	RC	E0710	CPT				Both			120	54	54	108		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	88.8							Fee Schedule																													108							Fee Schedule																																															
MITTS LG/XL HAND CONT. #79-91217 *DISC*	274	RC	E0710	CPT				Both			37.8	17.01	17.01	34.02		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	27.97							Fee Schedule																													34.02							Fee Schedule																																															
MITY VAC AMEDA EGNELL EXRACTION DEVICE	272	RC						Both			66.15	29.77	29.77	59.54	43							Fee Schedule		48.95							Fee Schedule																													59.54							Fee Schedule																																															
MMR II VACCINE	636	RC	90707	CPT				Both			132.39	59.58	54.12	119.15		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	97.97							Fee Schedule											54.12							Fee Schedule											119.15							Fee Schedule																																															
MOBISYL CREME	250	RC	A9270	CPT				Both			13.01	5.85	0.01	11.71	0.01							Fee Schedule		9.63							Fee Schedule																													11.71							Fee Schedule																																															
MODERNA COVID VACCINE ADMIN- BOOSTER	771	RC	0134A	CPT				Both			89.25	40.16	40.16	80.33	58.01							Fee Schedule		66.05							Fee Schedule																													80.33							Fee Schedule																																															
MODERNA COVID VACCINE ADMIN- DOSE 1	771	RC	0011A	CPT				Both			89.25	40.16	40.16	80.33	58.01							Fee Schedule		66.05							Fee Schedule																													80.33							Fee Schedule																																															
MODERNA COVID VACCINE ADMIN- DOSE 2	771	RC	0012A	CPT				Both			89.25	40.16	40.16	80.33	58.01							Fee Schedule		66.05							Fee Schedule																													80.33							Fee Schedule																																															
MODERNA COVID-19 VAX PED 25MCG SDV	636	RC	91321	CPT				Both			460.8	207.36	151.47	414.72		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	340.99							Fee Schedule		151.47							Fee Schedule																				414.72							Fee Schedule																																															
MODIFIED BA SWAL W SPEECH PATH	320	RC	74230	CPT				Both			315	141.75	36.83	318	84.01							Fee Schedule		91.76							Fee Schedule											36.83							Fee Schedule		147.06							Fee Schedule		283.5							Fee Schedule		169.12							Fee Schedule		136.77							Fee Schedule		318							Per Diem		169.12							Fee Schedule		136.77							Fee Schedule		
MOEXIPRIL 7.5MG (UNIVASC) TABLET	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
MOLECULAR CYTOGENETIS INTERPHASE IN SITU	301	RC	88274	CPT				Both			220.5	99.23	30.95	198.45	30.95							Fee Schedule		42.38							Fee Schedule		43.65							Fee Schedule		42.38							Fee Schedule											198.45							Fee Schedule																				42.38							Fee Schedule																				
MOLESKIN 1/16 X2 X 5YDS 5545723	270	RC						Both			26	11.7	11.7	48.74	16.9							Fee Schedule		19.24							Fee Schedule																				42.38							Fee Schedule		23.4							Fee Schedule		48.74							Fee Schedule		39.41							Fee Schedule											48.74							Fee Schedule		39.41							Fee Schedule		
MOLYBDENUM 6213 4ML SERUM	300	RC	83018	CPT				Both			118.65	53.39	19.53	106.79	19.53							Fee Schedule		24.41							Fee Schedule		22.62							Fee Schedule		21.96							Fee Schedule											106.79							Fee Schedule																				21.96							Fee Schedule																				
MOMETASONE 0.1% CREAM-15GM TUBE	250	RC	A9270	CPT				Both			91.85	41.33	0.01	82.67	0.01							Fee Schedule		67.97							Fee Schedule																				21.96							Fee Schedule		82.67							Fee Schedule		25.25							Fee Schedule		20.42							Fee Schedule											25.25							Fee Schedule		20.42							Fee Schedule		
MOMETASONE TWST 220 MCG MDI (ASMANEX)	250	RC	A9270	CPT				Both			284.22	127.9	0.01	255.8	0.01							Fee Schedule		210.32							Fee Schedule																													255.8							Fee Schedule																																															
MONISTAT 3 SUPP	250	RC	A9270	CPT				Both			30.49	13.72	0.01	27.44	0.01							Fee Schedule		22.56							Fee Schedule																													27.44							Fee Schedule																																															
MONISTAT 3 SUPP:200 MG	250	RC	A9270	CPT				Both			44.89	20.2	0.01	40.4	0.01							Fee Schedule		33.22							Fee Schedule																													40.4							Fee Schedule																																															
MONITOR BELTS KENDALL MEDLINE	270	RC	A4461	CPT				Both			5	2.25	2.25	4.84	2.97							Fee Schedule		3.7							Fee Schedule		4.84							Fee Schedule																				4.5							Fee Schedule																																															
MONKEYPOX VIRUS PCR (INTEGRITY LAB)	302	RC	87798	CPT				Both			300	135	4.37	270	31.2							Fee Schedule		38.99							Fee Schedule		36.14							Fee Schedule		35.09							Fee Schedule		4.7							Fee Schedule		270							Fee Schedule		5.41							Fee Schedule		4.37							Fee Schedule		35.09							Fee Schedule		5.41							Fee Schedule		4.37							Fee Schedule		
MONO TEST	302	RC	86308	CPT				Both			52.5	23.63	4.6	47.25	4.6							Fee Schedule		5.75							Fee Schedule		5.34							Fee Schedule		5.18							Fee Schedule		35.09							Fee Schedule		47.25							Fee Schedule		40.35							Fee Schedule		32.63							Fee Schedule		5.18							Fee Schedule		40.35							Fee Schedule		32.63							Fee Schedule		
MONOCRYL 0 Y358H	272	RC						Both			9	4.05	4.05	8.1	5.85							Fee Schedule		6.66							Fee Schedule																				5.18							Fee Schedule		8.1							Fee Schedule		5.96							Fee Schedule		4.82							Fee Schedule											5.96							Fee Schedule		4.82							Fee Schedule		
MONOCRYL 2.0 Y339H	272	RC						Both			5.25	2.36	2.36	4.73	3.41							Fee Schedule		3.89							Fee Schedule																													4.73							Fee Schedule																																															
MONOCRYL 2-0 Y732H	272	RC						Both			8	3.6	3.6	7.2	5.2							Fee Schedule		5.92							Fee Schedule																													7.2							Fee Schedule																																															
MONOCRYL 3.0 Y338H	272	RC						Both			7.35	3.31	3.31	6.62	4.78							Fee Schedule		5.44							Fee Schedule																													6.62							Fee Schedule																																															
MONOCRYL 3.0 Y497G	272	RC						Both			18	8.1	8.1	16.2	11.7							Fee Schedule		13.32							Fee Schedule																													16.2							Fee Schedule																																															
MONOCRYL 3-0 MCP523H	272	RC						Both			13	5.85	5.85	11.7	8.45							Fee Schedule		9.62							Fee Schedule																													11.7							Fee Schedule																																															
MONOCRYL 3-0 Y427H	272	RC						Both			22	9.9	9.9	19.8	14.3							Fee Schedule		16.28							Fee Schedule																													19.8							Fee Schedule																																															
MONOCRYL 3-0 Y738D (NS)	272	RC						Both			58	26.1	26.1	52.2	37.7							Fee Schedule		42.92							Fee Schedule																													52.2							Fee Schedule																																															
MONOCRYL 4.0  D9600	272	RC						Both			95	42.75	42.75	85.5	61.75							Fee Schedule		70.3							Fee Schedule																													85.5							Fee Schedule																																															
MONOCRYL 4.0 Y214H	272	RC						Both			7	3.15	3.15	6.3	4.55							Fee Schedule		5.18							Fee Schedule																													6.3							Fee Schedule																																															
MONOCRYL 4-0  MCP935H	272	RC						Both			13.13	5.91	5.91	11.82	8.53							Fee Schedule		9.72							Fee Schedule																													11.82							Fee Schedule																																															
MONOCRYL 4-0 MCP494G (WAS 1654G)	272	RC						Both			23	10.35	10.35	20.7	14.95							Fee Schedule		17.02							Fee Schedule																													20.7							Fee Schedule																																															
MONOCRYL 4-0 R691G	272	RC						Both			17.85	8.03	8.03	16.07	11.6							Fee Schedule		13.21							Fee Schedule																													16.07							Fee Schedule																																															
MONOCRYL 4-0 Y415H	272	RC						Both			7	3.15	3.15	6.3	4.55							Fee Schedule		5.18							Fee Schedule																													6.3							Fee Schedule																																															
MONOCRYL 4-0 Y496G	272	RC						Both			21	9.45	9.45	18.9	13.65							Fee Schedule		15.54							Fee Schedule																													18.9							Fee Schedule																																															
MONOCRYL 5.0 Y213H	272	RC						Both			8	3.6	3.6	7.2	5.2							Fee Schedule		5.92							Fee Schedule																													7.2							Fee Schedule																																															
MONOCRYL 5-0 Y844G	272	RC						Both			23	10.35	10.35	20.7	14.95							Fee Schedule		17.02							Fee Schedule																													20.7							Fee Schedule																																															
MONOCRYL 6.0 D9842	272	RC						Both			118	53.1	53.1	106.2	76.7							Fee Schedule		87.32							Fee Schedule																													106.2							Fee Schedule																																															
MONOCRYL BLUNT TIP  0  YB946	272	RC						Both			11	4.95	4.95	9.9	7.15							Fee Schedule		8.14							Fee Schedule																													9.9							Fee Schedule																																															
MONOCRYL V358H	272	RC						Both			11.55	5.2	5.2	10.4	7.51							Fee Schedule		8.55							Fee Schedule																													10.4							Fee Schedule																																															
MONOFIL WIRE ST/STEE	272	RC						Both			11.55	5.2	5.2	10.4	7.51							Fee Schedule		8.55							Fee Schedule																													10.4							Fee Schedule																																															
MONOLITH	272	RC						Both			954.45	429.5	429.5	859.01	620.39							Fee Schedule		706.29							Fee Schedule																													859.01							Fee Schedule																																															
MONOVISC 22MG/ML-4ML SYRINGE	636	RC	J7327	CPT				Both			4895.1	2202.8	581.71	4405.59		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	655.33							Fee Schedule		581.71							Fee Schedule																				4405.59							Fee Schedule																																															
MONSEL'S SOLUTION (FERRIC SUBSULFATE)	250	RC	A9270	CPT				Both			6.3	2.84	0.01	649.49	0.01							Fee Schedule		4.66							Fee Schedule																				564.77							Fee Schedule		5.67							Fee Schedule		649.49							Fee Schedule		525.24							Fee Schedule											649.49							Fee Schedule		525.24							Fee Schedule		
MONUROL (FOSFOMYCIN)	250	RC	A9270	CPT				Both			66.43	29.89	0.01	59.79	0.01							Fee Schedule		49.16							Fee Schedule																													59.79							Fee Schedule																																															
MORGAN LENS MT2000	272	RC						Both			90	40.5	40.5	81	58.5							Fee Schedule		66.6							Fee Schedule																													81							Fee Schedule																																															
MORPHINE  1 MG/ML PCA: HD + BASAL-100ML	636	RC	62326	CPT				Both			43.05	19.37	19.37	38.75		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	31.86							Fee Schedule																													38.75							Fee Schedule																																															
MORPHINE  1 MG/ML PCA: HD + BASAL-QUVA	636	RC	62326	CPT				Both			125.37	56.42	56.42	112.83		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	92.77							Fee Schedule																													112.83							Fee Schedule																																															
MORPHINE  1 MG/ML PCA: LD + BASAL-100ML	636	RC	62326	CPT				Both			43.05	19.37	19.37	38.75		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	31.86							Fee Schedule																													38.75							Fee Schedule																																															
MORPHINE  1 MG/ML PCA: LD + BASAL-QUVA	636	RC	62326	CPT				Both			125.37	56.42	56.42	112.83		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	92.77							Fee Schedule																													112.83							Fee Schedule																																															
MORPHINE  2 MG/ML INJECTION	636	RC	J2270	CPT				Both			12.6	5.67	0.96	11.34		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	9.32							Fee Schedule		8.33							Fee Schedule		0.96							Fee Schedule											11.34							Fee Schedule																																															
MORPHINE  8 MG/ML VIAL	636	RC	J2270	CPT				Both			10.5	4.73	0.96	9.45		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	7.77							Fee Schedule		8.33							Fee Schedule		0.96							Fee Schedule		8.09							Fee Schedule		9.45							Fee Schedule		9.3							Fee Schedule		7.52							Fee Schedule											9.3							Fee Schedule		7.52							Fee Schedule		
MORPHINE 1 MG/ML PCA: HIGH DOSE-100ML	636	RC	62326	CPT				Both			43.05	19.37	7.52	38.75		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	31.86							Fee Schedule																				8.09							Fee Schedule		38.75							Fee Schedule		9.3							Fee Schedule		7.52							Fee Schedule											9.3							Fee Schedule		7.52							Fee Schedule		
MORPHINE 1 MG/ML PCA: HIGH DOSE-QUVA	636	RC	62326	CPT				Both			125.37	56.42	56.42	112.83		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	92.77							Fee Schedule																													112.83							Fee Schedule																																															
MORPHINE 1 MG/ML PCA: LOW DOSE-100ML	636	RC	62326	CPT				Both			43.05	19.37	19.37	38.75		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	31.86							Fee Schedule																													38.75							Fee Schedule																																															
MORPHINE 1 MG/ML PCA: LOW DOSE-QUVA	636	RC	62326	CPT				Both			125.37	56.42	56.42	112.83		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	92.77							Fee Schedule																													112.83							Fee Schedule																																															
MORPHINE 1 MG/ML PCA-100ML (QuVa)	636	RC	J2270	CPT				Both			125.37	56.42	0.96	112.83		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	92.77							Fee Schedule		8.33							Fee Schedule		0.96							Fee Schedule											112.83							Fee Schedule																																															
MORPHINE 10 MG TAB	250	RC	A9270	CPT				Both			6.3	2.84	0.01	9.3	0.01							Fee Schedule		4.66							Fee Schedule																				8.09							Fee Schedule		5.67							Fee Schedule		9.3							Fee Schedule		7.52							Fee Schedule											9.3							Fee Schedule		7.52							Fee Schedule		
MORPHINE 10 MG/ML CARPUJECT	636	RC	J2270	CPT				Both			9.45	4.25	0.96	8.51		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	6.99							Fee Schedule		8.33							Fee Schedule		0.96							Fee Schedule											8.51							Fee Schedule																																															
MORPHINE 10 MG/ML INJECTION	636	RC	J2270	CPT				Both			12.6	5.67	0.96	11.34		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	9.32							Fee Schedule		8.33							Fee Schedule		0.96							Fee Schedule		8.09							Fee Schedule		11.34							Fee Schedule		9.3							Fee Schedule		7.52							Fee Schedule											9.3							Fee Schedule		7.52							Fee Schedule		
MORPHINE 10 MG/ML SYRINGE- FOR PCA ONLY	636	RC	J2270	CPT				Both			18.27	8.22	0.96	16.44		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	13.52							Fee Schedule		8.33							Fee Schedule		0.96							Fee Schedule		8.09							Fee Schedule		16.44							Fee Schedule		9.3							Fee Schedule		7.52							Fee Schedule											9.3							Fee Schedule		7.52							Fee Schedule		
MORPHINE 15 MG/ML	636	RC	J2270	CPT				Both			10.5	4.73	0.96	9.45		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	7.77							Fee Schedule		8.33							Fee Schedule		0.96							Fee Schedule		8.09							Fee Schedule		9.45							Fee Schedule		9.3							Fee Schedule		7.52							Fee Schedule											9.3							Fee Schedule		7.52							Fee Schedule		
MORPHINE 1MG/ML PCA: CUSTOM PROT-100ML	636	RC	62326	CPT				Both			43.05	19.37	7.52	38.75		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	31.86							Fee Schedule																				8.09							Fee Schedule		38.75							Fee Schedule		9.3							Fee Schedule		7.52							Fee Schedule											9.3							Fee Schedule		7.52							Fee Schedule		
MORPHINE 1MG/ML PCA: CUSTOM PROT-QUVA	636	RC	62326	CPT				Both			125.37	56.42	56.42	112.83		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	92.77							Fee Schedule																													112.83							Fee Schedule																																															
MORPHINE 20 MG/ML VIAL	636	RC	J2270	CPT				Both			18.9	8.51	0.96	17.01		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	13.99							Fee Schedule		8.33							Fee Schedule		0.96							Fee Schedule											17.01							Fee Schedule																																															
MORPHINE 30 MG TAB	250	RC	A9270	CPT				Both			6.3	2.84	0.01	9.3	0.01							Fee Schedule		4.66							Fee Schedule																				8.09							Fee Schedule		5.67							Fee Schedule		9.3							Fee Schedule		7.52							Fee Schedule											9.3							Fee Schedule		7.52							Fee Schedule		
MORPHINE SULF 15 MG ER (MS CONTIN) TAB	250	RC	A9270	CPT				Both			7.35	3.31	0.01	6.62	0.01							Fee Schedule		5.44							Fee Schedule																													6.62							Fee Schedule																																															
MORPHINE SULF 30 MG ER (MS CONTIN) TAB	250	RC	A9270	CPT				Both			10.5	4.73	0.01	9.45	0.01							Fee Schedule		7.77							Fee Schedule																													9.45							Fee Schedule																																															
MORPHINE SULFATE 10 MG/5ML ORAL SOL UD	250	RC	A9270	CPT				Both			7.35	3.31	0.01	6.62	0.01							Fee Schedule		5.44							Fee Schedule																													6.62							Fee Schedule																																															
MORPHINE SULFATE 10 MG/5ML ORAL SOLN UD	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
MORPHINE SULFATE 100MG ER TABLET UD	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
MORPHINE:4 MG/ML TUBEX	636	RC	J2270	CPT				Both			6.3	2.84	0.96	8.33		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	4.66							Fee Schedule		8.33							Fee Schedule		0.96							Fee Schedule											5.67							Fee Schedule																																															
MORPHOMETRIC ANAL NERVE	310	RC	88356	CPT				Both			525	236.25	7.52	472.5	61.83							Fee Schedule		87.59							Fee Schedule											102.29							Fee Schedule		8.09							Fee Schedule		472.5							Fee Schedule		9.3							Fee Schedule		7.52							Fee Schedule											9.3							Fee Schedule		7.52							Fee Schedule		
MORPHOMETRIC ANAL SKELETAL MUSCLE	310	RC	88355	CPT				Both			675.15	303.82	31.43	607.64	31.43							Fee Schedule		44.68							Fee Schedule											46.12							Fee Schedule											607.64							Fee Schedule																																															
MORPHOMETRIC ANAL TUMOR	310	RC	88358	CPT				Both			300.3	135.14	30.96	270.27	30.96							Fee Schedule		70							Fee Schedule											78.22							Fee Schedule											270.27							Fee Schedule																																															
MORPHOMETRIC ANALYSIS COMPUTER ASSISTED	310	RC	88361	CPT				Both			449.4	202.23	63.89	404.46	63.89							Fee Schedule		77.8							Fee Schedule											67.95							Fee Schedule											404.46							Fee Schedule																																															
MORPHOMETRIC ANALYSIS TUMOR MANUAL	312	RC	88360	CPT				Both			325	146.25	58.05	292.5	58.05							Fee Schedule		76.82							Fee Schedule											70.59							Fee Schedule											292.5							Fee Schedule																																															
MORRHUATE SODIUM 50 MG/ML MDV 30 ML	250	RC						Both			7.35	3.31	3.31	6.62	4.78							Fee Schedule		5.44							Fee Schedule																													6.62							Fee Schedule																																															
MOSAICPLASTY DISP. SYSTEM 3.5MM 7209234	272	RC						Both			1417.5	637.88	637.88	1275.75	921.38							Fee Schedule		1048.95							Fee Schedule																													1275.75							Fee Schedule																																															
MOSAICPLASTY DISP. SYSTEM 4.5MM 7209235	272	RC						Both			1417.5	637.88	637.88	1275.75	921.38							Fee Schedule		1048.95							Fee Schedule																													1275.75							Fee Schedule																																															
MOSAICPLASTY DISP. SYSTEM 6.5MM 7209236	272	RC						Both			1417.5	637.88	637.88	1275.75	921.38							Fee Schedule		1048.95							Fee Schedule																													1275.75							Fee Schedule																																															
MOTRIN SUSP.100 MG/5 ML (ER CHG.)	250	RC						Both			2.1	0.95	0.95	1.89	1.37							Fee Schedule		1.55							Fee Schedule																													1.89							Fee Schedule																																															
MOTRIN SUSP.100 MG/5 ML (ER CHG.)	250	RC	A9270	CPT				Both			5.25	2.36	0.01	4.73	0.01							Fee Schedule		3.89							Fee Schedule																													4.73							Fee Schedule																																															
MOUNTAIN ORTH CLAVICLE PLATE PL-CL8ML	278	RC	C1713	CPT				Both			2137.8	962.01	962.01	1924.02		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1581.97							Fee Schedule																													1924.02							Fee Schedule																																															
MOUNTAIN ORTH DRILL BIT MS-DC28	272	RC						Both			95.55	43	43	86	62.11							Fee Schedule		70.71							Fee Schedule																													86							Fee Schedule																																															
MOUNTAIN ORTH DRILL BIT MS-DC5020	272	RC						Both			95.55	43	43	86	62.11							Fee Schedule		70.71							Fee Schedule																													86							Fee Schedule																																															
MOUNTAIN ORTH LOCKING SCREW COL-3140	278	RC	C1713	CPT				Both			236.25	106.31	106.31	212.63		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	174.83							Fee Schedule																													212.63							Fee Schedule																																															
MOUNTAIN ORTH NON-LOCKING SCREW CO-3120	278	RC	C1713	CPT				Both			202.65	91.19	91.19	182.39		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	149.96							Fee Schedule																													182.39							Fee Schedule																																															
MOUNTAIN ORTH NON-LOCKING SCREW CO-3140	278	RC	C1713	CPT				Both			202.65	91.19	91.19	182.39		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	149.96							Fee Schedule																													182.39							Fee Schedule																																															
MOUNTAIN ORTH SOCKING SCREW COL-3140	278	RC	C1713	CPT				Both			236.25	106.31	106.31	212.63		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	174.83							Fee Schedule																													212.63							Fee Schedule																																															
MOUTH SEAL	271	RC						Both			5.25	2.36	2.36	4.73	3.41							Fee Schedule		3.89							Fee Schedule																													4.73							Fee Schedule																																															
MOUTHGAG SILICONE BITE LINER RUSABLE	270	RC						Both			34.65	15.59	15.59	31.19	22.52							Fee Schedule		25.64							Fee Schedule																													31.19							Fee Schedule																																															
MOUTHPIECE FOR SP2 SPIROMETER #2.100118	270	RC						Both			15	6.75	6.75	13.5	9.75							Fee Schedule		11.1							Fee Schedule																													13.5							Fee Schedule																																															
MOVANTIK 25MG TABLET	250	RC	A9270	CPT				Both			45.15	20.32	0.01	40.64	0.01							Fee Schedule		33.41							Fee Schedule																													40.64							Fee Schedule																																															
MRA ABD W CONTRAST	618	RC	74185	CPT				Both			2205	992.25	278.66	2546	750							Per Diem		278.66							Fee Schedule											313.29							Fee Schedule											1984.5							Fee Schedule																				2546							Case Rate																				
MRA ABD WO CONTRAST	618	RC	74185	CPT				Both			2205	992.25	278.66	2546	750							Per Diem		278.66							Fee Schedule											313.29							Fee Schedule											1984.5							Fee Schedule																				2546							Case Rate																				
MRA ABD WWO CONTRAST	618	RC	74183	CPT				Both			2205	992.25	263.4	2546	750							Per Diem		263.4							Fee Schedule											704.76							Fee Schedule											1984.5							Fee Schedule																				2546							Case Rate																				
MRA BRAIN W CONT	615	RC	70545	CPT				Both			2205	992.25	196.83	2546	750							Per Diem		196.83							Fee Schedule											320.06							Fee Schedule											1984.5							Fee Schedule																				2546							Case Rate																				
MRA BRAIN WO CONT MRV	615	RC	70544	CPT				Both			2205	992.25	198.78	2546	750							Per Diem		198.78							Fee Schedule											320.06							Fee Schedule											1984.5							Fee Schedule																				2546							Case Rate																				
MRA BRAIN WWO CONT	615	RC	70546	CPT				Both			2205	992.25	304.82	2546	750							Per Diem		304.82							Fee Schedule											631.14							Fee Schedule											1984.5							Fee Schedule																				2546							Case Rate																				
MRA CHEST W CONT	618	RC	71555	CPT				Both			2205	992.25	275.41	2546	750							Per Diem		275.41							Fee Schedule											313.29							Fee Schedule											1984.5							Fee Schedule																				2546							Case Rate																				
MRA CHEST WO CONT	618	RC	71555	CPT				Both			2205	992.25	275.41	2546	750							Per Diem		275.41							Fee Schedule											313.29							Fee Schedule											1984.5							Fee Schedule																				2546							Case Rate																				
MRA CHEST WWO CONT	618	RC	71555	CPT				Both			2205	992.25	275.41	2546	750							Per Diem		275.41							Fee Schedule											313.29							Fee Schedule											1984.5							Fee Schedule																				2546							Case Rate																				
MRA LOW EXT W CONT	616	RC	73725	CPT				Both			2205	992.25	277.36	2546	750							Per Diem		277.36							Fee Schedule											313.29							Fee Schedule											1984.5							Fee Schedule																				2546							Case Rate																				
MRA LOW EXT WO CONT	616	RC	73725	CPT				Both			2205	992.25	277.36	2546	750							Per Diem		277.36							Fee Schedule											313.29							Fee Schedule											1984.5							Fee Schedule																				2546							Case Rate																				
MRA LOW EXT WWO CONT	616	RC	73725	CPT				Both			2205	992.25	277.36	2546	750							Per Diem		277.36							Fee Schedule											313.29							Fee Schedule											1984.5							Fee Schedule																				2546							Case Rate																				
MRA NECK W CONT	615	RC	70548	CPT				Both			2205	992.25	211.44	2546	750							Per Diem		211.44							Fee Schedule											320.06							Fee Schedule											1984.5							Fee Schedule																				2546							Case Rate																				
MRA NECK WO CONT	615	RC	70547	CPT				Both			2205	992.25	199.75	2546	750							Per Diem		199.75							Fee Schedule											320.06							Fee Schedule											1984.5							Fee Schedule																				2546							Case Rate																				
MRA NECK WWO CONT	615	RC	70549	CPT				Both			2205	992.25	306.77	2546	750							Per Diem		306.77							Fee Schedule											631.14							Fee Schedule											1984.5							Fee Schedule																				2546							Case Rate																				
MRA PELVIS W CONT	618	RC	72198	CPT				Both			2205	992.25	277.68	2546	750							Per Diem		277.68							Fee Schedule											313.29							Fee Schedule											1984.5							Fee Schedule																				2546							Case Rate																				
MRA PELVIS WO CONT	618	RC	72198	CPT				Both			2205	992.25	277.68	2546	750							Per Diem		277.68							Fee Schedule											313.29							Fee Schedule											1984.5							Fee Schedule																				2546							Case Rate																				
MRA PELVIS WWO CONT	618	RC	72198	CPT				Both			2205	992.25	277.68	2546	750							Per Diem		277.68							Fee Schedule											313.29							Fee Schedule											1984.5							Fee Schedule																				2546							Case Rate																				
MRA UPPER EXT WWO	618	RC	C8936	CPT				Both			2205	992.25	336.2	2546	750							Per Diem		385.88							Fee Schedule		367.12							Fee Schedule		336.2							Fee Schedule											1984.5							Fee Schedule																				2546							Case Rate																				
MRCP	610	RC	74181	CPT				Both			2205	992.25	155.73	2546	750							Per Diem		155.73							Fee Schedule											317.38							Fee Schedule		356.43							Fee Schedule		1984.5							Fee Schedule		409.89							Fee Schedule		331.48							Fee Schedule		2546							Case Rate		409.89							Fee Schedule		331.48							Fee Schedule		
MRI ABDOMEN W CONT	610	RC	74182	CPT				Both			2205	992.25	247.81	2546	750							Per Diem		247.81							Fee Schedule											380.82							Fee Schedule											1984.5							Fee Schedule																				2546							Case Rate																				
MRI ABDOMEN WO CONT	610	RC	74181	CPT				Both			2205	992.25	155.73	2546	750							Per Diem		155.73							Fee Schedule											317.38							Fee Schedule											1984.5							Fee Schedule																				2546							Case Rate																				
MRI ABDOMEN WWO CONT	610	RC	74183	CPT				Both			2205	992.25	263.4	2546	750							Per Diem		263.4							Fee Schedule											704.76							Fee Schedule											1984.5							Fee Schedule																				2546							Case Rate																				
MRI BRAIN W CONT	611	RC	70552	CPT				Both			2205	992.25	204.95	2546	750							Per Diem		204.95							Fee Schedule											380.65							Fee Schedule											1984.5							Fee Schedule																				2546							Case Rate																				
MRI BRAIN WO CONT	611	RC	70551	CPT				Both			2205	992.25	138.52	2546	750							Per Diem		138.52							Fee Schedule											317.38							Fee Schedule											1984.5							Fee Schedule																				2546							Case Rate																				
MRI BRAIN WWO CONT	611	RC	70553	CPT				Both			2205	992.25	233.52	2546	750							Per Diem		233.52							Fee Schedule											704.92							Fee Schedule											1984.5							Fee Schedule																				2546							Case Rate																				
MRI BREAST BILATERAL W&WO INC CAD	610	RC	77049	CPT				Both			2205	992.25	214.26	2546	750							Per Diem		263.72							Fee Schedule											214.26							Fee Schedule											1984.5							Fee Schedule																				2546							Case Rate																				
MRI BREAST BILATERAL WO CONTRAST	610	RC	77047	CPT				Both			2205	992.25	129.95	2546	750							Per Diem		159.95							Fee Schedule											129.95							Fee Schedule											1984.5							Fee Schedule																				2546							Case Rate																				
MRI BREAST LOCALIZATION 1ST	320	RC	19287	CPT				Both			2100	945	140.85	1890	140.85							Fee Schedule		1554							Fee Schedule																													1890							Fee Schedule																				318							Per Diem																				
MRI BREAST LOCALIZATION ADDITIONAL	320	RC	19288	CPT				Both			2100	945	71.06	1890	71.06							Fee Schedule		1554							Fee Schedule																													1890							Fee Schedule																				318							Per Diem																				
MRI BREAST UNILATERAL W&WO CONTRAST CAD	618	RC	77048	CPT				Both			2205	992.25	215.31	2546	750							Per Diem		265.02							Fee Schedule											215.31							Fee Schedule											1984.5							Fee Schedule																				2546							Case Rate																				
MRI BREAST UNILATERAL WITHOUT CONTRAST	618	RC	77046	CPT				Both			2205	992.25	130.74	2546	750							Per Diem		160.92							Fee Schedule											130.74							Fee Schedule											1984.5							Fee Schedule																				2546							Case Rate																				
MRI CERVICAL W CONT	612	RC	72142	CPT				Both			2205	992.25	210.14	2546	750							Per Diem		210.14							Fee Schedule											380.65							Fee Schedule											1984.5							Fee Schedule																				2546							Case Rate																				
MRI CERVICAL WO CONT	612	RC	72141	CPT				Both			2205	992.25	133	2546	750							Per Diem		133							Fee Schedule											317.38							Fee Schedule											1984.5							Fee Schedule																				2546							Case Rate																				
MRI CERVICAL WWO CONT	612	RC	72156	CPT				Both			2205	992.25	235.8	2546	750							Per Diem		235.8							Fee Schedule											704.92							Fee Schedule											1984.5							Fee Schedule																				2546							Case Rate																				
MRI CHEST MEDST W CONT	610	RC	71551	CPT				Both			2205	992.25	329.96	2546	750							Per Diem		329.96							Fee Schedule											380.82							Fee Schedule											1984.5							Fee Schedule																				2546							Case Rate																				
MRI CHEST MEDST WO CONT	610	RC	71550	CPT				Both			2205	992.25	215.37	2546	750							Per Diem		303.01							Fee Schedule		215.37							Fee Schedule		317.38							Fee Schedule											1984.5							Fee Schedule																				2546							Case Rate																				
MRI CHEST MEDST WWO CONT	610	RC	71552	CPT				Both			2205	992.25	194.46	2546	750							Per Diem		413.28							Fee Schedule		314.85							Fee Schedule		701.2							Fee Schedule		209.1							Fee Schedule		1984.5							Fee Schedule		240.47							Fee Schedule		194.46							Fee Schedule		2546							Case Rate		240.47							Fee Schedule		194.46							Fee Schedule		
MRI CONTRAST DOTERAM	255	RC	A9575	CPT				Both			358.05	161.12	0.09	351.53	0.18							Fee Schedule		264.96							Fee Schedule		0.09							Fee Schedule											305.68							Fee Schedule		322.25							Fee Schedule		351.53							Fee Schedule		284.28							Fee Schedule											351.53							Fee Schedule		284.28							Fee Schedule		
MRI GUIDANCE NEEDLE PLACEMENT	610	RC	77021	CPT				Both			2205	992.25	0.08	2546	750							Per Diem		368.6							Fee Schedule											297.78							Fee Schedule		0.09							Fee Schedule		1984.5							Fee Schedule		0.1							Fee Schedule		0.08							Fee Schedule		2546							Case Rate		0.1							Fee Schedule		0.08							Fee Schedule		
MRI GUIDED BREAST BIOPSY ADDITIONAL	320	RC	19086	CPT				Both			2100	945	101.02	1890	101.02							Fee Schedule		1554							Fee Schedule																													1890							Fee Schedule																				318							Per Diem																				
MRI JNT LOW EXT L W CONT	610	RC	73722	CPT				Both			2205	992.25	265.99	2546	750							Per Diem		265.99							Fee Schedule											380.11							Fee Schedule											1984.5							Fee Schedule																				2546							Case Rate																				
MRI JNT LOW EXT L WWO CONT	610	RC	73723	CPT				Both			2205	992.25	321.52	2546	750							Per Diem		321.52							Fee Schedule											703.69							Fee Schedule											1984.5							Fee Schedule																				2546							Case Rate																				
MRI JNT LOW EXT LEFT WO CONT	610	RC	73721	CPT				Both			2205	992.25	150.07	2546	750							Per Diem		150.07							Fee Schedule											317.38							Fee Schedule											1984.5							Fee Schedule																				2546							Case Rate																				
MRI JNT LOW EXT R W CONT	610	RC	73722	CPT				Both			2205	992.25	265.99	2546	750							Per Diem		265.99							Fee Schedule											380.11							Fee Schedule											1984.5							Fee Schedule																				2546							Case Rate																				
MRI JNT LOW EXT R WO CONT	610	RC	73721	CPT				Both			2205	992.25	150.07	2546	750							Per Diem		150.07							Fee Schedule											317.38							Fee Schedule											1984.5							Fee Schedule																				2546							Case Rate																				
MRI JNT LOW EXT R WWO CONT	610	RC	73723	CPT				Both			2205	992.25	321.52	2546	750							Per Diem		321.52							Fee Schedule											703.69							Fee Schedule											1984.5							Fee Schedule																				2546							Case Rate																				
MRI JNT UP EXT L W CONT	610	RC	73222	CPT				Both			2205	992.25	264.37	2546	750							Per Diem		264.37							Fee Schedule											380.11							Fee Schedule											1984.5							Fee Schedule																				2546							Case Rate																				
MRI JNT UP EXT L WO CONT	610	RC	73221	CPT				Both			2205	992.25	150.07	2546	750							Per Diem		150.07							Fee Schedule											317.38							Fee Schedule											1984.5							Fee Schedule																				2546							Case Rate																				
MRI JNT UP EXT L WWO CONT	610	RC	73223	CPT				Both			2205	992.25	322.17	2546	750							Per Diem		322.17							Fee Schedule											703.69							Fee Schedule											1984.5							Fee Schedule																				2546							Case Rate																				
MRI JNT UP EXT R W CONT	610	RC	73222	CPT				Both			2205	992.25	264.37	2546	750							Per Diem		264.37							Fee Schedule											380.11							Fee Schedule											1984.5							Fee Schedule																				2546							Case Rate																				
MRI JNT UP EXT R WO CONT	610	RC	73221	CPT				Both			2205	992.25	150.07	2546	750							Per Diem		150.07							Fee Schedule											317.38							Fee Schedule											1984.5							Fee Schedule																				2546							Case Rate																				
MRI JNT UP EXT R WWO CONT	610	RC	73223	CPT				Both			2205	992.25	322.17	2546	750							Per Diem		322.17							Fee Schedule											703.69							Fee Schedule											1984.5							Fee Schedule																				2546							Case Rate																				
MRI LOW EXT L W CONT	610	RC	73719	CPT				Both			2205	992.25	208.52	2546	750							Per Diem		208.52							Fee Schedule											380.11							Fee Schedule											1984.5							Fee Schedule																				2546							Case Rate																				
MRI LOW EXT L WO CONT	610	RC	73718	CPT				Both			2205	992.25	177.48	2546	750							Per Diem		177.48							Fee Schedule											317.04							Fee Schedule											1984.5							Fee Schedule																				2546							Case Rate																				
MRI LOW EXT L WWO CONT	610	RC	73720	CPT				Both			2205	992.25	264.69	2546	750							Per Diem		264.69							Fee Schedule											317.38							Fee Schedule											1984.5							Fee Schedule																				2546							Case Rate																				
MRI LOW EXT R W CONT	610	RC	73719	CPT				Both			2205	992.25	208.52	2546	750							Per Diem		208.52							Fee Schedule											380.11							Fee Schedule											1984.5							Fee Schedule																				2546							Case Rate																				
MRI LOW EXT R WO CONT	610	RC	73718	CPT				Both			2205	992.25	177.48	2546	750							Per Diem		177.48							Fee Schedule											317.04							Fee Schedule											1984.5							Fee Schedule																				2546							Case Rate																				
MRI LOW EXT R WWO CONT	610	RC	73720	CPT				Both			2205	992.25	264.69	2546	750							Per Diem		264.69							Fee Schedule											317.38							Fee Schedule											1984.5							Fee Schedule																				2546							Case Rate																				
MRI LUMBAR W CONT	612	RC	72149	CPT				Both			2205	992.25	206.57	2546	750							Per Diem		206.57							Fee Schedule											380.65							Fee Schedule											1984.5							Fee Schedule																				2546							Case Rate																				
MRI LUMBAR WO CONT	612	RC	72148	CPT				Both			2205	992.25	133.32	2546	750							Per Diem		133.32							Fee Schedule											352.4							Fee Schedule											1984.5							Fee Schedule																				2546							Case Rate																				
MRI LUMBAR WWO CONT	612	RC	72158	CPT				Both			2205	992.25	235.15	2546	750							Per Diem		235.15							Fee Schedule											704.92							Fee Schedule											1984.5							Fee Schedule																				2546							Case Rate																				
MRI ORBIT/FACE W CONT	610	RC	70542	CPT				Both			2205	992.25	213.39	2546	750							Per Diem		213.39							Fee Schedule											380.11							Fee Schedule											1984.5							Fee Schedule																				2546							Case Rate																				
MRI ORBIT/FACE WO CONT	610	RC	70540	CPT				Both			2205	992.25	180.4	2546	750							Per Diem		180.4							Fee Schedule											317.38							Fee Schedule											1984.5							Fee Schedule																				2546							Case Rate																				
MRI ORBIT/FACE WWO CONT	610	RC	70543	CPT				Both			2205	992.25	263.72	2546	750							Per Diem		263.72							Fee Schedule											703.69							Fee Schedule											1984.5							Fee Schedule																				2546							Case Rate																				
MRI PELVIS W CONT	610	RC	72196	CPT				Both			2205	992.25	208.52	2546	750							Per Diem		208.52							Fee Schedule											317.38							Fee Schedule											1984.5							Fee Schedule																				2546							Case Rate																				
MRI PELVIS WO CONT	610	RC	72195	CPT				Both			2205	992.25	179.76	2546	750							Per Diem		179.76							Fee Schedule											317.94							Fee Schedule											1984.5							Fee Schedule																				2546							Case Rate																				
MRI PELVIS WWO CONT	610	RC	72197	CPT				Both			2205	992.25	263.07	2546	750							Per Diem		263.07							Fee Schedule											704.76							Fee Schedule											1984.5							Fee Schedule																				2546							Case Rate																				
MRI THORACIC W CONT	612	RC	72147	CPT				Both			2205	992.25	208.84	2546	750							Per Diem		208.84							Fee Schedule											380.65							Fee Schedule											1984.5							Fee Schedule																				2546							Case Rate																				
MRI THORACIC WO CONT	612	RC	72146	CPT				Both			2205	992.25	133.32	2546	750							Per Diem		133.32							Fee Schedule											352.4							Fee Schedule											1984.5							Fee Schedule																				2546							Case Rate																				
MRI THORACIC WWO CONT	612	RC	72157	CPT				Both			2205	992.25	236.77	2546	750							Per Diem		236.77							Fee Schedule											704.92							Fee Schedule											1984.5							Fee Schedule																				2546							Case Rate																				
MRI TMJ WO CONT	610	RC	70336	CPT				Both			2205	992.25	219.56	2546	750							Per Diem		219.56							Fee Schedule											317.38							Fee Schedule											1984.5							Fee Schedule																				2546							Case Rate																				
MRI UP EXT L W CONT	610	RC	73219	CPT				Both			2205	992.25	285.48	2546	750							Per Diem		285.48							Fee Schedule											380.11							Fee Schedule											1984.5							Fee Schedule																				2546							Case Rate																				
MRI UP EXT L WO CONT	610	RC	73218	CPT				Both			2205	992.25	265.67	2546	750							Per Diem		265.67							Fee Schedule											317.04							Fee Schedule											1984.5							Fee Schedule																				2546							Case Rate																				
MRI UP EXT L WWO CONT	610	RC	73220	CPT				Both			2205	992.25	317.38	2546	750							Per Diem		347.17							Fee Schedule											317.38							Fee Schedule											1984.5							Fee Schedule																				2546							Case Rate																				
MRI UP EXT R W CONT	610	RC	73219	CPT				Both			2205	992.25	285.48	2546	750							Per Diem		285.48							Fee Schedule											380.11							Fee Schedule											1984.5							Fee Schedule																				2546							Case Rate																				
MRI UP EXT R WO CONT	610	RC	73218	CPT				Both			2205	992.25	265.67	2546	750							Per Diem		265.67							Fee Schedule											317.04							Fee Schedule											1984.5							Fee Schedule																				2546							Case Rate																				
MRI UP EXT R WWO CONT	610	RC	73220	CPT				Both			2205	992.25	317.38	2546	750							Per Diem		347.17							Fee Schedule											317.38							Fee Schedule											1984.5							Fee Schedule																				2546							Case Rate																				
MRO REVIEW	471	RC						Both			15	6.75	6.75	199	9.75							Fee Schedule		11.1							Fee Schedule																													13.5							Fee Schedule																				199							Per Diem																				
MRSA SCREEN	306	RC	87081	CPT				Both			45.15	20.32	5.89	40.64	5.89							Fee Schedule		7.36							Fee Schedule		6.83							Fee Schedule		6.63							Fee Schedule											40.64							Fee Schedule																				6.63							Fee Schedule																				
MSIR CONC SOL 20 MG/1 ML	250	RC	A9270	CPT				Both			6.3	2.84	0.01	7.62	0.01							Fee Schedule		4.66							Fee Schedule																				6.63							Fee Schedule		5.67							Fee Schedule		7.62							Fee Schedule		6.17							Fee Schedule											7.62							Fee Schedule		6.17							Fee Schedule		
MTHFR DNA MUTATION 17911 5ML EDTA W BLD	310	RC	81291	CPT				Both			526.05	236.72	47.04	473.45	47.04							Fee Schedule		65.34							Fee Schedule		67.3							Fee Schedule		65.34							Fee Schedule											473.45							Fee Schedule																																															
"MUCO-FEN 800MG SR (GUIAFENSIN LA, Q-BID)"	250	RC	A9270	CPT				Both			4.2	1.89	0.01	75.14	0.01							Fee Schedule		3.11							Fee Schedule																				65.34							Fee Schedule		3.78							Fee Schedule		75.14							Fee Schedule		60.77							Fee Schedule											75.14							Fee Schedule		60.77							Fee Schedule		
MUCOMYST 200MG/ML(20%) 4 ML VIAL	250	RC	J7608	CPT				Both			23.1	10.4	5.69	20.79	5.69							Fee Schedule		17.09							Fee Schedule		7.49							Fee Schedule																				20.79							Fee Schedule																																															
MUCOSAL  ATOMIZATION DEVICE #MAD100	270	RC						Both			15.75	7.09	6.76	14.18	10.24							Fee Schedule		11.66							Fee Schedule																				7.27							Fee Schedule		14.18							Fee Schedule		8.37							Fee Schedule		6.76							Fee Schedule											8.37							Fee Schedule		6.76							Fee Schedule		
MUCOUS TRAP	272	RC						Both			8.4	3.78	3.78	7.56	5.46							Fee Schedule		6.22							Fee Schedule																													7.56							Fee Schedule																																															
MUCOUS TRAP 70CC DYND44180  MEDLINE	272	RC						Both			3	1.35	1.35	2.7	1.95							Fee Schedule		2.22							Fee Schedule																													2.7							Fee Schedule																																															
MUCOUS TRAP MEDLINE 40CC DYND44140	272	RC						Both			3	1.35	1.35	2.7	1.95							Fee Schedule		2.22							Fee Schedule																													2.7							Fee Schedule																																															
MUCOUS TRAP W/VACUUM	272	RC						Both			9.45	4.25	4.25	8.51	6.14							Fee Schedule		6.99							Fee Schedule																													8.51							Fee Schedule																																															
MULTI ORIW/SOFT CONE	272	RC						Both			55.65	25.04	25.04	50.09	36.17							Fee Schedule		41.18							Fee Schedule																													50.09							Fee Schedule																																															
MULTI SLEEP LATENCY	740	RC	95811	CPT				Outpatient			2333.1	1049.9	209.96	2099.79	1300							Per Diem		1726.49							Fee Schedule											209.96							Fee Schedule											2099.79							Fee Schedule																				286							Per Diem																				
MULTI TRACE 10 ML	250	RC						Both			52.5	23.63	23.63	47.25	34.13							Fee Schedule		38.85							Fee Schedule																													47.25							Fee Schedule																																															
MULTI TRACE 10 ML VIAL	250	RC						Both			6.3	2.84	2.84	5.67	4.1							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
MULTIDEX GEL 46-712	272	RC	A6248	CPT				Both			60.9	27.41	14.63	54.81	14.63							Fee Schedule		45.07							Fee Schedule		23.84							Fee Schedule		18.29							Fee Schedule											54.81							Fee Schedule																																															
MULTIDEX POWDER 46-701-1	272	RC	A6262	CPT				Both			47	21.15	0.52	42.3	0.52							Fee Schedule		34.78							Fee Schedule																				23.15							Fee Schedule		42.3							Fee Schedule		26.62							Fee Schedule		21.53							Fee Schedule											26.62							Fee Schedule		21.53							Fee Schedule		
MULTIGEN  (CHROMAGEN)  CAPSULE	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
MULTIPLE SLEEP LATENCY	740	RC	95805	CPT				Both			2333.1	1049.9	158.56	2099.79	1300							Per Diem		1726.49							Fee Schedule											158.56							Fee Schedule											2099.79							Fee Schedule																				286							Per Diem																				
MULTI-VITAMIN  LIQUID 15ML-UD	250	RC	A9270	CPT				Both			7.74	3.48	0.01	6.97	0.01							Fee Schedule		5.73							Fee Schedule																													6.97							Fee Schedule																																															
MUMPS AB IGG 8624 1ML SERUM	302	RC	86735	CPT				Both			38.85	17.48	11.6	34.97	11.6							Fee Schedule		14.5							Fee Schedule		13.44							Fee Schedule		13.05							Fee Schedule											34.97							Fee Schedule																				13.05							Fee Schedule																				
MUMPS AB IGM 36565 1ML SERUM	302	RC	86735	CPT				Both			38.85	17.48	11.6	34.97	11.6							Fee Schedule		14.5							Fee Schedule		13.44							Fee Schedule		13.05							Fee Schedule		13.05							Fee Schedule		34.97							Fee Schedule		15.01							Fee Schedule		12.14							Fee Schedule		13.05							Fee Schedule		15.01							Fee Schedule		12.14							Fee Schedule		
MUMPS SKIN TEST	250	RC						Both			4.2	1.89	1.89	15.01	2.73							Fee Schedule		3.11							Fee Schedule																				13.05							Fee Schedule		3.78							Fee Schedule		15.01							Fee Schedule		12.14							Fee Schedule											15.01							Fee Schedule		12.14							Fee Schedule		
"MUMPS VIRUS RNA,QUAL PCR 70172"	302	RC	87798	CPT				Both			405	182.25	31.2	364.5	31.2							Fee Schedule		38.99							Fee Schedule		36.14							Fee Schedule		35.09							Fee Schedule											364.5							Fee Schedule																				35.09							Fee Schedule																				
MUPIROCIN 2%  NASAL OINT-1 GM(BACTROBAN)	250	RC	A9270	CPT				Both			15.75	7.09	0.01	40.35	0.01							Fee Schedule		11.66							Fee Schedule																				35.09							Fee Schedule		14.18							Fee Schedule		40.35							Fee Schedule		32.63							Fee Schedule											40.35							Fee Schedule		32.63							Fee Schedule		
MUPIROCIN 2% (BACTROBAN) CREAM-15GM	250	RC	A9270	CPT				Both			735.48	330.97	0.01	661.93	0.01							Fee Schedule		544.26							Fee Schedule																													661.93							Fee Schedule																																															
MUPIROCIN 2% (BACTROBAN) OINTMENT-22GM	250	RC	A9270	CPT				Both			78.75	35.44	0.01	70.88	0.01							Fee Schedule		58.28							Fee Schedule																													70.88							Fee Schedule																																															
MURAMIDASE 619	305	RC	85549	CPT				Both			105	47.25	16.67	94.5	16.67							Fee Schedule		20.83							Fee Schedule		19.31							Fee Schedule		18.75							Fee Schedule											94.5							Fee Schedule																				18.75							Fee Schedule																				
MURO-128 OPTH OINT 5%	250	RC						Both			46.75	21.04	17.44	42.08	30.39							Fee Schedule		34.6							Fee Schedule																				18.75							Fee Schedule		42.08							Fee Schedule		21.56							Fee Schedule		17.44							Fee Schedule											21.56							Fee Schedule		17.44							Fee Schedule		
MUSCLE BIOPSY CLAMP 12MM SU130-1112	272	RC						Both			91	40.95	40.95	81.9	59.15							Fee Schedule		67.34							Fee Schedule																													81.9							Fee Schedule																																															
MUSHROOM CATHETER 086030	272	RC						Both			108	48.6	48.6	97.2	70.2							Fee Schedule		79.92							Fee Schedule																													97.2							Fee Schedule																																															
MUSTANG BALLOON CATH H74939171040470	272	RC	C1725	CPT				Both			840	378	93.3	756	93.3							Fee Schedule		621.6							Fee Schedule																													756							Fee Schedule																																															
MUSTANG BALLOON CATH H74939171050210	272	RC	C1725	CPT				Both			840	378	93.3	756	93.3							Fee Schedule		621.6							Fee Schedule																													756							Fee Schedule																																															
MUSTANG BALLOON CATH H74939171050610	272	RC	C1725	CPT				Both			840	378	93.3	756	93.3							Fee Schedule		621.6							Fee Schedule																													756							Fee Schedule																																															
MUSTANG BALLOON CATH H74939171051210	272	RC	C1725	CPT				Both			840	378	93.3	756	93.3							Fee Schedule		621.6							Fee Schedule																													756							Fee Schedule																																															
MUSTANG BALLOON CATH H74939171060210	272	RC	C1725	CPT				Both			840	378	93.3	756	93.3							Fee Schedule		621.6							Fee Schedule																													756							Fee Schedule																																															
MUSTANG BALLOON CATH H74939171060410	272	RC	C1725	CPT				Both			840	378	93.3	756	93.3							Fee Schedule		621.6							Fee Schedule																													756							Fee Schedule																																															
MUSTANG BALLOON CATH H74939171060470	272	RC	C1725	CPT				Both			840	378	93.3	756	93.3							Fee Schedule		621.6							Fee Schedule																													756							Fee Schedule																																															
MUSTANG BALLOON CATH H74939171060610	272	RC	C1725	CPT				Both			840	378	93.3	756	93.3							Fee Schedule		621.6							Fee Schedule																													756							Fee Schedule																																															
MUSTANG BALLOON CATH H74939171061010	272	RC	C1725	CPT				Both			840	378	93.3	756	93.3							Fee Schedule		621.6							Fee Schedule																													756							Fee Schedule																																															
MUSTANG BALLOON CATH H74939171061210	272	RC	C1725	CPT				Both			840	378	93.3	756	93.3							Fee Schedule		621.6							Fee Schedule																													756							Fee Schedule																																															
MUSTANG BALLOON CATH H74939171070410	272	RC	C1725	CPT				Both			840	378	93.3	756	93.3							Fee Schedule		621.6							Fee Schedule																													756							Fee Schedule																																															
MUSTANG BALLOON CATH H74939171070810	272	RC	C1725	CPT				Both			840	378	93.3	756	93.3							Fee Schedule		621.6							Fee Schedule																													756							Fee Schedule																																															
MUSTANG BALLOON CATH H74939171080410	272	RC	C1725	CPT				Both			840	378	93.3	756	93.3							Fee Schedule		621.6							Fee Schedule																													756							Fee Schedule																																															
MUSTANG BALLOON CATH H74939171080470	272	RC	C1725	CPT				Both			840	378	93.3	756	93.3							Fee Schedule		621.6							Fee Schedule																													756							Fee Schedule																																															
MUSTANG BALLOON CATH H74939171100410	278	RC	C1725	CPT				Both			840	378	378	756		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	621.6							Fee Schedule																													756							Fee Schedule																																															
MVI-12 VIAL 10 ML	250	RC	A9270	CPT				Both			128.1	57.65	0.01	115.29	0.01							Fee Schedule		94.79							Fee Schedule																													115.29							Fee Schedule																																															
MYADEC	250	RC	A9270	CPT				Both			1.58	0.71	0.01	1.42	0.01							Fee Schedule		1.17							Fee Schedule																													1.42							Fee Schedule																																															
MYASTHENIA GRAVIS PANEL 1  7550	302	RC	83519	CPT				Both			143.85	64.73	13.25	129.47	13.25							Fee Schedule		18.4							Fee Schedule		18.95							Fee Schedule		18.4							Fee Schedule											129.47							Fee Schedule																				18.4							Fee Schedule																				
MYCOBACTERIUM TB COMPLEX PCR 30298 SPUT	306	RC	87118	CPT				Both			240.45	108.2	10.52	216.41	10.52							Fee Schedule		14.61							Fee Schedule		15.05							Fee Schedule		14.61							Fee Schedule		18.4							Fee Schedule		216.41							Fee Schedule		21.16							Fee Schedule		17.11							Fee Schedule		14.61							Fee Schedule		21.16							Fee Schedule		17.11							Fee Schedule		
MYCOLOG CR 15 GMS	250	RC	A9270	CPT				Both			7.56	3.4	0.01	16.8	0.01							Fee Schedule		5.59							Fee Schedule																				14.61							Fee Schedule		6.8							Fee Schedule		16.8							Fee Schedule		13.59							Fee Schedule											16.8							Fee Schedule		13.59							Fee Schedule		
MYCOPHENOLIC ACID 10662 SERUM 1 ML	301	RC	80299	CPT				Both			178.5	80.33	13.42	160.65	13.42							Fee Schedule		18.64							Fee Schedule		19.2							Fee Schedule		18.64							Fee Schedule											160.65							Fee Schedule																				18.64							Fee Schedule																				
MYCOPLASMA CULT SPINAL FLUID 4554	306	RC	87109	CPT				Both			124.95	56.23	13.68	112.46	13.68							Fee Schedule		17.1							Fee Schedule		15.85							Fee Schedule		15.39							Fee Schedule		18.64							Fee Schedule		112.46							Fee Schedule		21.44							Fee Schedule		17.34							Fee Schedule		15.39							Fee Schedule		21.44							Fee Schedule		17.34							Fee Schedule		
MYCOPLASMA CULT SPUTUM 4554	306	RC	87109	CPT				Both			124.95	56.23	13.68	112.46	13.68							Fee Schedule		17.1							Fee Schedule		15.85							Fee Schedule		15.39							Fee Schedule		15.39							Fee Schedule		112.46							Fee Schedule		17.7							Fee Schedule		14.31							Fee Schedule		15.39							Fee Schedule		17.7							Fee Schedule		14.31							Fee Schedule		
MYCOPLASMA GENITALIUM AMPLIFIED PROBE TE	306	RC	87563	CPT				Both			468	210.6	14.31	421.2	25.26							Fee Schedule		35.09							Fee Schedule		36.14							Fee Schedule		35.09							Fee Schedule		15.39							Fee Schedule		421.2							Fee Schedule		17.7							Fee Schedule		14.31							Fee Schedule		35.09							Fee Schedule		17.7							Fee Schedule		14.31							Fee Schedule		
MYCOPLASMA HOMINIS CULTURE 871	306	RC	87109	CPT				Both			48	21.6	13.68	43.2	13.68							Fee Schedule		17.1							Fee Schedule		15.85							Fee Schedule		15.39							Fee Schedule		35.09							Fee Schedule		43.2							Fee Schedule		40.35							Fee Schedule		32.63							Fee Schedule		15.39							Fee Schedule		40.35							Fee Schedule		32.63							Fee Schedule		
MYCOPLASMA PNEUMON IGG 659 SERUM	302	RC	86738	CPT				Both			74.55	33.55	11.76	67.1	11.76							Fee Schedule		14.71							Fee Schedule		13.64							Fee Schedule		13.24							Fee Schedule		15.39							Fee Schedule		67.1							Fee Schedule		17.7							Fee Schedule		14.31							Fee Schedule		13.24							Fee Schedule		17.7							Fee Schedule		14.31							Fee Schedule		
MYCOPLASMA PNEUMON IGM 21130 SERUM	300	RC	86738	CPT				Both			109.2	49.14	11.76	98.28	11.76							Fee Schedule		14.71							Fee Schedule		13.64							Fee Schedule		13.24							Fee Schedule		13.24							Fee Schedule		98.28							Fee Schedule		15.23							Fee Schedule		12.31							Fee Schedule		13.24							Fee Schedule		15.23							Fee Schedule		12.31							Fee Schedule		
MYCOPLASMA PNEUMONIAE AB 21130	306	RC	87109	CPT				Both			124.95	56.23	12.31	112.46	13.68							Fee Schedule		17.1							Fee Schedule		15.85							Fee Schedule		15.39							Fee Schedule		13.24							Fee Schedule		112.46							Fee Schedule		15.23							Fee Schedule		12.31							Fee Schedule		15.39							Fee Schedule		15.23							Fee Schedule		12.31							Fee Schedule		
MYELIN BASIC PROTEIN 663 CSF	301	RC	83873	CPT				Both			94.5	42.53	14.31	85.05	15.29							Fee Schedule		19.12							Fee Schedule		17.72							Fee Schedule		17.2							Fee Schedule		15.39							Fee Schedule		85.05							Fee Schedule		17.7							Fee Schedule		14.31							Fee Schedule		17.2							Fee Schedule		17.7							Fee Schedule		14.31							Fee Schedule		
MYELOGRAM 2 OR MORE LOCATIONS	320	RC	72270	CPT				Both			689.85	310.43	16	620.87	49.37							Fee Schedule		61.56							Fee Schedule											172.55							Fee Schedule		17.2							Fee Schedule		620.87							Fee Schedule		19.78							Fee Schedule		16							Fee Schedule		318							Per Diem		19.78							Fee Schedule		16							Fee Schedule		
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROC					516	DRG		Inpatient			13588.89	6115	6115	6115							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period	
MYLANTA MAXIMUM STRENGH SUSPENSION-355ML	250	RC	A9270	CPT				Both			9.45	4.25	0.01	8.51	0.01							Fee Schedule		6.99							Fee Schedule																													8.51							Fee Schedule																																															
MYLANTA MAXIMUM STRENGTH	250	RC	A9270	CPT				Both			1.58	0.71	0.01	1.42	0.01							Fee Schedule		1.17							Fee Schedule																													1.42							Fee Schedule																																															
MYLICON DROPS 15ML	250	RC	A9270	CPT				Both			11.55	5.2	0.01	10.4	0.01							Fee Schedule		8.55							Fee Schedule																													10.4							Fee Schedule																																															
MYOCHRISINE 50 MG/ML- 10ML MDV	636	RC	J1600	CPT				Both			68.25	30.71	20.17	61.43		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	50.51							Fee Schedule											20.17							Fee Schedule											61.43							Fee Schedule																																															
MYOFLEX CREME	250	RC	A9270	CPT				Both			17.61	7.92	0.01	15.85	0.01							Fee Schedule		13.03							Fee Schedule																													15.85							Fee Schedule																																															
MYOGLOBIN	301	RC	83874	CPT				Both			80.85	36.38	11.48	72.77	11.48							Fee Schedule		14.35							Fee Schedule		13.31							Fee Schedule		12.92							Fee Schedule											72.77							Fee Schedule																				12.92							Fee Schedule																				
"MYOGLOBIN, URINE 13834"	301	RC	83874	CPT				Both			135	60.75	11.48	121.5	11.48							Fee Schedule		14.35							Fee Schedule		13.31							Fee Schedule		12.92							Fee Schedule		12.92							Fee Schedule		121.5							Fee Schedule		14.86							Fee Schedule		12.02							Fee Schedule		12.92							Fee Schedule		14.86							Fee Schedule		12.02							Fee Schedule		
MYOSURE HYSTEROSCOPE SEAL CAPS #40-904	270	RC						Both			135	60.75	12.02	121.5	87.75							Fee Schedule		99.9							Fee Schedule																				12.92							Fee Schedule		121.5							Fee Schedule		14.86							Fee Schedule		12.02							Fee Schedule											14.86							Fee Schedule		12.02							Fee Schedule		
MYOSURE SINGLE USE SEAL SET 40-902	270	RC						Both			31	13.95	13.95	27.9	20.15							Fee Schedule		22.94							Fee Schedule																													27.9							Fee Schedule																																															
MYRBETRIQ 25MG ER TABLET	250	RC	A9270	CPT				Both			40.95	18.43	0.01	36.86	0.01							Fee Schedule		30.3							Fee Schedule																													36.86							Fee Schedule																																															
MYSOLINE LIQ:PER OZ	250	RC	A9270	CPT				Both			12.63	5.68	0.01	11.37	0.01							Fee Schedule		9.35							Fee Schedule																													11.37							Fee Schedule																																															
N TELOPEPTIDE NTX SERUM 17406	305	RC	82523	CPT				Both			90.3	40.64	16.61	81.27	16.61							Fee Schedule		20.76							Fee Schedule		19.24							Fee Schedule		18.68							Fee Schedule											81.27							Fee Schedule																				18.68							Fee Schedule																				
N TELOPEPTIDE NTX URINE 2HR SP  36167	305	RC	82523	CPT				Both			90.3	40.64	16.61	81.27	16.61							Fee Schedule		20.76							Fee Schedule		19.24							Fee Schedule		18.68							Fee Schedule		18.68							Fee Schedule		81.27							Fee Schedule		21.48							Fee Schedule		17.37							Fee Schedule		18.68							Fee Schedule		21.48							Fee Schedule		17.37							Fee Schedule		
NA BICARB ADULT 7.5	250	RC						Both			14.7	6.62	6.62	21.48	9.56							Fee Schedule		10.88							Fee Schedule																				18.68							Fee Schedule		13.23							Fee Schedule		21.48							Fee Schedule		17.37							Fee Schedule											21.48							Fee Schedule		17.37							Fee Schedule		
NABI-HB (HEPATITIS-B IMMUNE GLOBULIN)5ML	636	RC	90371	CPT				Both			546	245.7	70.24	491.4		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	70.24							Fee Schedule		141.06							Fee Schedule		175.89							Fee Schedule											491.4							Fee Schedule																																															
NABUMETONE 500MG (RELAFEN) TABLET	250	RC	A9270	CPT				Both			6.3	2.84	0.01	157.49	0.01							Fee Schedule		4.66							Fee Schedule																				136.95							Fee Schedule		5.67							Fee Schedule		157.49							Fee Schedule		127.37							Fee Schedule											157.49							Fee Schedule		127.37							Fee Schedule		
NAC 600MG CAPSULE	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
NADOLOL 40MG (CORGARD) TABLET	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
NAFCILLIN 1 GRAM  VIAL	250	RC						Both			63	28.35	28.35	56.7	40.95							Fee Schedule		46.62							Fee Schedule																													56.7							Fee Schedule																																															
NAFCILLIN 2 GRAM VIAL	250	RC	J2290	CPT				Both			91.35	41.11	0.05	82.22	59.38							Fee Schedule		67.6							Fee Schedule		0.05							Fee Schedule																				82.22							Fee Schedule																																															
NAFCILLIN 2GM/NS 100ML	250	RC	J2290	CPT				Both			45	20.25	0.04	40.5	29.25							Fee Schedule		33.3							Fee Schedule		0.05							Fee Schedule											0.05							Fee Schedule		40.5							Fee Schedule		0.05							Fee Schedule		0.04							Fee Schedule											0.05							Fee Schedule		0.04							Fee Schedule		
NAIL DRIVING GUIDE	272	RC						Both			152.25	68.51	0.04	137.03	98.96							Fee Schedule		112.67							Fee Schedule																				0.05							Fee Schedule		137.03							Fee Schedule		0.05							Fee Schedule		0.04							Fee Schedule											0.05							Fee Schedule		0.04							Fee Schedule		
NALBUPHINE 10MG/1ML (NUBAIN) AMPULE	636	RC	J2300	CPT				Both			12.6	5.67	4.42	11.34		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	9.32							Fee Schedule		4.42							Fee Schedule		5.16							Fee Schedule											11.34							Fee Schedule																																															
NALDECON EX DROPS-30ML	250	RC	A9270	CPT				Both			20.48	9.22	0.01	18.43	0.01							Fee Schedule		15.16							Fee Schedule																				4.29							Fee Schedule		18.43							Fee Schedule		4.93							Fee Schedule		3.99							Fee Schedule											4.93							Fee Schedule		3.99							Fee Schedule		
NALDECON PED SYRUP	250	RC	A9270	CPT				Both			1.58	0.71	0.01	1.42	0.01							Fee Schedule		1.17							Fee Schedule																													1.42							Fee Schedule																																															
NALDECON SYRUP:OZ	250	RC	A9270	CPT				Both			1.62	0.73	0.01	1.46	0.01							Fee Schedule		1.2							Fee Schedule																													1.46							Fee Schedule																																															
NALDECON TABLET	250	RC	A9270	CPT				Both			1.58	0.71	0.01	1.42	0.01							Fee Schedule		1.17							Fee Schedule																													1.42							Fee Schedule																																															
NALFON 600 MG TABLET UD	250	RC	A9270	CPT				Both			1.58	0.71	0.01	1.42	0.01							Fee Schedule		1.17							Fee Schedule																													1.42							Fee Schedule																																															
NALOXONE 0.4 MG/ML (NARCAN) VIAL	636	RC	J2312	CPT				Both			59.85	26.93	0.07	53.87		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	44.29							Fee Schedule		0.07							Fee Schedule																				53.87							Fee Schedule																																															
NALOXONE 0.4 MG/ML CARPUJECT	636	RC	J2313	CPT				Both			55.59	25.02	0.06	50.03		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	41.14							Fee Schedule																				0.07							Fee Schedule		50.03							Fee Schedule		0.08							Fee Schedule		0.06							Fee Schedule											0.08							Fee Schedule		0.06							Fee Schedule		
NALOXONE 0.4 MG/ML-10ML INJECTION	636	RC	J2312	CPT				Both			18.9	8.51	0.07	17.01		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	13.99							Fee Schedule		0.07							Fee Schedule																				17.01							Fee Schedule																																															
NALOXONE 10MG/ NS 50ML IVPB (PEDIATRIC)	258	RC	J2312	CPT				Both			630	283.5	0.06	567	409.5							Fee Schedule		466.2							Fee Schedule		0.07							Fee Schedule											0.07							Fee Schedule		567							Fee Schedule		0.08							Fee Schedule		0.06							Fee Schedule											0.08							Fee Schedule		0.06							Fee Schedule		
NALOXONE 1MG/ML (NARCAN)-2ML SYRINGE	636	RC	J2312	CPT				Both			124.95	56.23	0.06	112.46		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	92.46							Fee Schedule		0.07							Fee Schedule											0.07							Fee Schedule		112.46							Fee Schedule		0.08							Fee Schedule		0.06							Fee Schedule											0.08							Fee Schedule		0.06							Fee Schedule		
NALOXONE 2MG/ NS 500ML IVPB (ADULT)	258	RC	J2312	CPT				Both			130.65	58.79	0.06	117.59	84.92							Fee Schedule		96.68							Fee Schedule		0.07							Fee Schedule											0.07							Fee Schedule		117.59							Fee Schedule		0.08							Fee Schedule		0.06							Fee Schedule											0.08							Fee Schedule		0.06							Fee Schedule		
NAPHCON A OPTH SOL	250	RC	A9270	CPT				Both			27.3	12.29	0.01	24.57	0.01							Fee Schedule		20.2							Fee Schedule																				0.07							Fee Schedule		24.57							Fee Schedule		0.08							Fee Schedule		0.06							Fee Schedule											0.08							Fee Schedule		0.06							Fee Schedule		
NAPHCON-A OPTH DROPS	250	RC	A9270	CPT				Both			10.5	4.73	0.01	9.45	0.01							Fee Schedule		7.77							Fee Schedule																													9.45							Fee Schedule																																															
NAPROXEN 250 MG TABLET UD	250	RC	A9270	CPT				Both			4.2	1.89	0.01	3.78	0.01							Fee Schedule		3.11							Fee Schedule																													3.78							Fee Schedule																																															
NAPROXEN 375MG (NAPROSYN) TABLET	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
NAPROXEN 500MG (NAPROSYN) TABLET	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
NAPROXEN 550MG (ANAPROX DS) TABLET	250	RC	A9270	CPT				Both			13.65	6.14	0.01	12.29	0.01							Fee Schedule		10.1							Fee Schedule																													12.29							Fee Schedule																																															
NARCAN 4MG NASAL SPRAY	250	RC	A9270	CPT				Both			236.25	106.31	0.01	212.63	0.01							Fee Schedule		174.83							Fee Schedule																													212.63							Fee Schedule																																															
NARCAN ADULT	636	RC	J2310	CPT				Both			19.95	8.98	8.98	17.96		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	14.76							Fee Schedule																													17.96							Fee Schedule																																															
NARCAN NEO NATAL 0.2	636	RC	J2310	CPT				Both			18.9	8.51	8.51	17.01		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	13.99							Fee Schedule																													17.01							Fee Schedule																																															
NAROPIN 0.2% 100 ML PREMIX	636	RC	J2795	CPT				Both			108	48.6	0.04	97.2		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	79.92							Fee Schedule		0.04							Fee Schedule																				97.2							Fee Schedule																																															
NAROPIN 0.5% - 20 ML SDV	636	RC	J2795	CPT				Both			59.46	26.76	0.04	53.51		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	44							Fee Schedule		0.04							Fee Schedule											0.04							Fee Schedule		53.51							Fee Schedule		0.04							Fee Schedule		0.04							Fee Schedule											0.04							Fee Schedule		0.04							Fee Schedule		
NAROPIN 0.5%-30ML SDV	636	RC	J2795	CPT				Both			56.07	25.23	0.04	50.46		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	41.49							Fee Schedule		0.04							Fee Schedule											0.04							Fee Schedule		50.46							Fee Schedule		0.04							Fee Schedule		0.04							Fee Schedule											0.04							Fee Schedule		0.04							Fee Schedule		
NASACORT ALLERGY 24HR SPRAY- 10.8ML	250	RC	J3535	CPT				Both			42.46	19.11	0.04	38.21	27.6							Fee Schedule		31.42							Fee Schedule																				0.04							Fee Schedule		38.21							Fee Schedule		0.04							Fee Schedule		0.04							Fee Schedule											0.04							Fee Schedule		0.04							Fee Schedule		
NASACORT INHALER	636	RC	J3535	CPT				Both			131.42	59.14	59.14	118.28		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	97.25							Fee Schedule																													118.28							Fee Schedule																																															
NASAL AIRWAY 14FR 18542014	271	RC						Both			26	11.7	11.7	23.4	16.9							Fee Schedule		19.24							Fee Schedule																													23.4							Fee Schedule																																															
NASAL AIRWAY 16FR 18542016	271	RC						Both			29	13.05	13.05	26.1	18.85							Fee Schedule		21.46							Fee Schedule																													26.1							Fee Schedule																																															
NASAL AIRWAY 18FR 18542018	271	RC						Both			26	11.7	11.7	23.4	16.9							Fee Schedule		19.24							Fee Schedule																													23.4							Fee Schedule																																															
NASAL AIRWAY 20FR 18542020	271	RC						Both			26	11.7	11.7	23.4	16.9							Fee Schedule		19.24							Fee Schedule																													23.4							Fee Schedule																																															
NASAL AIRWAY 22FR 18542022	271	RC						Both			29	13.05	13.05	26.1	18.85							Fee Schedule		21.46							Fee Schedule																													26.1							Fee Schedule																																															
NASAL AIRWAY 24FR 18542024	271	RC						Both			26	11.7	11.7	23.4	16.9							Fee Schedule		19.24							Fee Schedule																													23.4							Fee Schedule																																															
NASAL AIRWAY 26FR 18542026	271	RC						Both			29	13.05	13.05	26.1	18.85							Fee Schedule		21.46							Fee Schedule																													26.1							Fee Schedule																																															
NASAL AIRWAY TRUMPET 26FR #1-5076-26	272	RC						Both			7	3.15	3.15	6.3	4.55							Fee Schedule		5.18							Fee Schedule																													6.3							Fee Schedule																																															
NASAL AIRWAY TRUMPET 28FR #1-5076-28	271	RC						Both			17.85	8.03	8.03	16.07	11.6							Fee Schedule		13.21							Fee Schedule																													16.07							Fee Schedule																																															
NASAL AIRWAY TRUMPET 28FR DYNJNASO28	271	RC						Both			9	4.05	4.05	8.1	5.85							Fee Schedule		6.66							Fee Schedule																													8.1							Fee Schedule																																															
NASAL AIRWAY TRUMPET 30FR #1-5076-30	271	RC						Both			7	3.15	3.15	6.3	4.55							Fee Schedule		5.18							Fee Schedule																													6.3							Fee Schedule																																															
NASAL AIRWAY TRUMPET 32FR #1-5076-32	271	RC						Both			7	3.15	3.15	6.3	4.55							Fee Schedule		5.18							Fee Schedule																													6.3							Fee Schedule																																															
NASAL BONES	320	RC	70160	CPT				Both			315	141.75	15.04	318	19.67							Fee Schedule		23.24							Fee Schedule											15.04							Fee Schedule											283.5							Fee Schedule																				318							Per Diem																				
NASAL CANNULA  25' #HUD8525 (301-115)	272	RC	A4615	CPT				Both			3	1.35	0.66	2.7	0.66							Fee Schedule		2.22							Fee Schedule		1.07							Fee Schedule		0.82							Fee Schedule											2.7							Fee Schedule																																															
NASAL CANNULA  HI FLOW 7'  ( SENECA )	272	RC	A4615	CPT				Both			6.75	3.04	0.66	6.08	0.66							Fee Schedule		5							Fee Schedule		1.07							Fee Schedule		0.82							Fee Schedule		1.04							Fee Schedule		6.08							Fee Schedule		1.2							Fee Schedule		0.97							Fee Schedule											1.2							Fee Schedule		0.97							Fee Schedule		
NASAL CANNULA 1101 HUDSON	272	RC	A4615	CPT				Both			6.3	2.84	0.66	5.67	0.66							Fee Schedule		4.66							Fee Schedule		1.07							Fee Schedule		0.82							Fee Schedule		1.04							Fee Schedule		5.67							Fee Schedule		1.2							Fee Schedule		0.97							Fee Schedule											1.2							Fee Schedule		0.97							Fee Schedule		
NASAL CANNULA 1104 HUDSON	272	RC	A4615	CPT				Both			3.15	1.42	0.66	2.84	0.66							Fee Schedule		2.33							Fee Schedule		1.07							Fee Schedule		0.82							Fee Schedule		1.04							Fee Schedule		2.84							Fee Schedule		1.2							Fee Schedule		0.97							Fee Schedule											1.2							Fee Schedule		0.97							Fee Schedule		
NASAL CANNULA 2FT SLP A/15805-2FT-50	271	RC						Both			14	6.3	0.97	12.6	9.1							Fee Schedule		10.36							Fee Schedule																				1.04							Fee Schedule		12.6							Fee Schedule		1.2							Fee Schedule		0.97							Fee Schedule											1.2							Fee Schedule		0.97							Fee Schedule		
NASAL CANNULA 7' #HUD8507 (301-113)	272	RC	A4615	CPT				Both			1	0.45	0.45	1.07	0.66							Fee Schedule		0.74							Fee Schedule		1.07							Fee Schedule		0.82							Fee Schedule											0.9							Fee Schedule																																															
NASAL CANNULA BRAEBON # 0589 SLEEP LAB	270	RC	A4615	CPT				Both			15	6.75	0.66	13.5	0.66							Fee Schedule		11.1							Fee Schedule		1.07							Fee Schedule		0.82							Fee Schedule		1.04							Fee Schedule		13.5							Fee Schedule		1.2							Fee Schedule		0.97							Fee Schedule											1.2							Fee Schedule		0.97							Fee Schedule		
NASAL CANNULA H.F. W/O RESERV. P3000	272	RC	A4615	CPT				Both			10	4.5	0.66	9	0.66							Fee Schedule		7.4							Fee Schedule		1.07							Fee Schedule		0.82							Fee Schedule		1.04							Fee Schedule		9							Fee Schedule		1.2							Fee Schedule		0.97							Fee Schedule											1.2							Fee Schedule		0.97							Fee Schedule		
NASAL CANNULA H.F. W/O RESERVOIR 25'	272	RC	A4615	CPT				Both			15.5	6.98	0.66	13.95	0.66							Fee Schedule		11.47							Fee Schedule		1.07							Fee Schedule		0.82							Fee Schedule		1.04							Fee Schedule		13.95							Fee Schedule		1.2							Fee Schedule		0.97							Fee Schedule											1.2							Fee Schedule		0.97							Fee Schedule		
NASAL CANNULA HIGH FLOW 25'	272	RC	A4615	CPT				Both			13	5.85	0.66	11.7	0.66							Fee Schedule		9.62							Fee Schedule		1.07							Fee Schedule		0.82							Fee Schedule		1.04							Fee Schedule		11.7							Fee Schedule		1.2							Fee Schedule		0.97							Fee Schedule											1.2							Fee Schedule		0.97							Fee Schedule		
NASAL CANNULA INFANT N4903 NEOTECH CHS	272	RC	A4615	CPT				Both			32	14.4	0.66	28.8	0.66							Fee Schedule		23.68							Fee Schedule		1.07							Fee Schedule		0.82							Fee Schedule		1.04							Fee Schedule		28.8							Fee Schedule		1.2							Fee Schedule		0.97							Fee Schedule											1.2							Fee Schedule		0.97							Fee Schedule		
NASAL CANNULA NEWBORN N4902 NEOTECH CHS	272	RC	A4615	CPT				Both			33	14.85	0.66	29.7	0.66							Fee Schedule		24.42							Fee Schedule		1.07							Fee Schedule		0.82							Fee Schedule		1.04							Fee Schedule		29.7							Fee Schedule		1.2							Fee Schedule		0.97							Fee Schedule											1.2							Fee Schedule		0.97							Fee Schedule		
NASAL CANNULA PEDIATRIC # 301-130	270	RC	A4615	CPT				Both			5	2.25	0.66	4.5	0.66							Fee Schedule		3.7							Fee Schedule		1.07							Fee Schedule		0.82							Fee Schedule		1.04							Fee Schedule		4.5							Fee Schedule		1.2							Fee Schedule		0.97							Fee Schedule											1.2							Fee Schedule		0.97							Fee Schedule		
NASAL CANNULA PREEMIE N4901 NEOTECH CHS	272	RC	A4615	CPT				Both			33	14.85	0.66	29.7	0.66							Fee Schedule		24.42							Fee Schedule		1.07							Fee Schedule		0.82							Fee Schedule		1.04							Fee Schedule		29.7							Fee Schedule		1.2							Fee Schedule		0.97							Fee Schedule											1.2							Fee Schedule		0.97							Fee Schedule		
NASAL DECONGEST 0.05% (AFRIN)SPRAY-30ML	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																				1.04							Fee Schedule		5.67							Fee Schedule		1.2							Fee Schedule		0.97							Fee Schedule											1.2							Fee Schedule		0.97							Fee Schedule		
NASAL JEJUNAL FEEDING TUBE  NJFT-10	270	RC						Both			294	132.3	132.3	264.6	191.1							Fee Schedule		217.56							Fee Schedule																													264.6							Fee Schedule																																															
NASAL JEJUNAL FEEDING TUBE  NJFT-8	270	RC						Both			346.5	155.93	155.93	311.85	225.23							Fee Schedule		256.41							Fee Schedule																													311.85							Fee Schedule																																															
NASAL O2 CATHER 10FR 1145	271	RC						Both			3.15	1.42	1.42	2.84	2.05							Fee Schedule		2.33							Fee Schedule																													2.84							Fee Schedule																																															
NASAL PACK BILT. 5.5 RHINO	271	RC						Both			223	100.35	100.35	200.7	144.95							Fee Schedule		165.02							Fee Schedule																													200.7							Fee Schedule																																															
NASAL PACK RHINO ROCKET SLIM MEDIUM	271	RC						Both			52	23.4	23.4	46.8	33.8							Fee Schedule		38.48							Fee Schedule																													46.8							Fee Schedule																																															
NASAL PACK W/ GEL 5.5CM RHINO NEW RP-55	271	RC						Both			75	33.75	33.75	67.5	48.75							Fee Schedule		55.5							Fee Schedule																													67.5							Fee Schedule																																															
NASAL PACK W/ GEL 7.5CM RHINO NEW RP-75	271	RC						Both			75	33.75	33.75	67.5	48.75							Fee Schedule		55.5							Fee Schedule																													67.5							Fee Schedule																																															
NASAL PACK W/GEL 5.5 RHINO	271	RC						Both			162	72.9	72.9	145.8	105.3							Fee Schedule		119.88							Fee Schedule																													145.8							Fee Schedule																																															
NASAL PACK W/GEL 7.5 RHINO	271	RC						Both			165	74.25	74.25	148.5	107.25							Fee Schedule		122.1							Fee Schedule																													148.5							Fee Schedule																																															
NASAL PACKING	272	RC						Both			70.35	31.66	31.66	63.32	45.73							Fee Schedule		52.06							Fee Schedule																													63.32							Fee Schedule																																															
NASAL SMEAR FOR EOS 426	309	RC	89190	CPT				Both			26.25	11.81	4.22	23.63	4.22							Fee Schedule		5.79							Fee Schedule		5.96							Fee Schedule		5.79							Fee Schedule											23.63							Fee Schedule																				5.79							Fee Schedule																				
NASAL SPLINT(MEDTRONIC) 1524050	271	RC						Both			221	99.45	5.38	198.9	143.65							Fee Schedule		163.54							Fee Schedule																				5.79							Fee Schedule		198.9							Fee Schedule		6.66							Fee Schedule		5.38							Fee Schedule											6.66							Fee Schedule		5.38							Fee Schedule		
NASAL SPONGE MEROCEL	272	RC						Both			54.6	24.57	24.57	49.14	35.49							Fee Schedule		40.4							Fee Schedule																													49.14							Fee Schedule																																															
NASAL SPONGE POPE FLEX PAK (XOMED)460406	272	RC						Both			128	57.6	57.6	115.2	83.2							Fee Schedule		94.72							Fee Schedule																													115.2							Fee Schedule																																															
NASAL TUBE FASTNERS	271	RC						Both			6.3	2.84	2.84	5.67	4.1							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
NASALCROM NASAL SOL 13 ML	250	RC	J3535	CPT				Both			26.9	12.11	12.11	24.21	17.49							Fee Schedule		19.91							Fee Schedule																													24.21							Fee Schedule																																															
NASAREL SOL.0.025% INHALER	636	RC	J3535	CPT				Both			150.15	67.57	67.57	135.14		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	111.11							Fee Schedule																													135.14							Fee Schedule																																															
NASONEX NASAL SPRAY 50MCG	250	RC	A9270	CPT				Both			299.25	134.66	0.01	269.33	0.01							Fee Schedule		221.45							Fee Schedule																													269.33							Fee Schedule																																															
NATEGLINIDE (STARLIX) 120MG TABLET	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
NAVANE 1 MG CAPS	250	RC	A9270	CPT				Both			1.58	0.71	0.01	1.42	0.01							Fee Schedule		1.17							Fee Schedule																													1.42							Fee Schedule																																															
NAVANE CONC ORAL SOL	250	RC	A9270	CPT				Both			121.09	54.49	0.01	108.98	0.01							Fee Schedule		89.61							Fee Schedule																													108.98							Fee Schedule																																															
NAVIFLEX BILIARY STENT #M00533580	278	RC	C1874	CPT				Both			253	113.85	113.85	227.7		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	187.22							Fee Schedule																													227.7							Fee Schedule																																															
NAVIGATOR URETERAL SHEATH #M0062502240	272	RC						Both			402	180.9	180.9	361.8	261.3							Fee Schedule		297.48							Fee Schedule																													361.8							Fee Schedule																																															
NAVIGATOR URETERAL SHEATH #M0062502250	272	RC						Both			401	180.45	180.45	360.9	260.65							Fee Schedule		296.74							Fee Schedule																													360.9							Fee Schedule																																															
NAVIGATOR URETERAL SHEATH #M0062502260	272	RC						Both			401	180.45	180.45	360.9	260.65							Fee Schedule		296.74							Fee Schedule																													360.9							Fee Schedule																																															
NB RESUSCITATION	370	RC	99465	CPT				Both			1300	585	121.46	1170	160.22							Fee Schedule		962							Fee Schedule											121.46							Fee Schedule											1170							Fee Schedule																																															
NEBCIN : 80MG	636	RC	J3260	CPT				Both			24.15	10.87	2.25	21.74		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	17.87							Fee Schedule		2.25							Fee Schedule		8.66							Fee Schedule											21.74							Fee Schedule																																															
NEBCIN:80 MG	636	RC	J3260	CPT				Both			52.98	23.84	2.03	47.68		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	39.21							Fee Schedule		2.25							Fee Schedule		8.66							Fee Schedule		2.19							Fee Schedule		47.68							Fee Schedule		2.51							Fee Schedule		2.03							Fee Schedule											2.51							Fee Schedule		2.03							Fee Schedule		
NEBULIZER 3 MINUTE 8960-7 ( TRIANIM )	271	RC						Both			8	3.6	2.03	7.2	5.2							Fee Schedule		5.92							Fee Schedule																				2.19							Fee Schedule		7.2							Fee Schedule		2.51							Fee Schedule		2.03							Fee Schedule											2.51							Fee Schedule		2.03							Fee Schedule		
NEBULIZER 8900  SALTER	271	RC						Both			3	1.35	1.35	2.7	1.95							Fee Schedule		2.22							Fee Schedule																													2.7							Fee Schedule																																															
NEBULIZER CONTINUOUS # 11-4100 (SENECA)	271	RC						Both			28.35	12.76	12.76	25.52	18.43							Fee Schedule		20.98							Fee Schedule																													25.52							Fee Schedule																																															
NEBULIZER MISTY FINITY # 002534 ( SENECA	271	RC						Both			19.43	8.74	8.74	17.49	12.63							Fee Schedule		14.38							Fee Schedule																													17.49							Fee Schedule																																															
NEBULIZER THERAMIST #301-P3000N (SENECA)	271	RC						Both			23	10.35	10.35	20.7	14.95							Fee Schedule		17.02							Fee Schedule																													20.7							Fee Schedule																																															
NEBULIZER WATER BOTTLE #5207 (TRIANIM)	270	RC						Both			24	10.8	10.8	21.6	15.6							Fee Schedule		17.76							Fee Schedule																													21.6							Fee Schedule																																															
NECK EXT	278	RC	C1776	CPT				Both			330.75	148.84	148.84	297.68		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	244.76							Fee Schedule																													297.68							Fee Schedule																																															
NEEDLE 27 GAUGE LONG (PATTERSON DENTAL)	272	RC	A4215	CPT				Both			2.1	0.95	0.13	1.89	0.15							Fee Schedule		1.55							Fee Schedule											0.13							Fee Schedule											1.89							Fee Schedule																																															
NEEDLE BIOPSY SOFT TISSUE 2N2702X	272	RC						Both			50	22.5	22.5	45	32.5							Fee Schedule		37							Fee Schedule																													45							Fee Schedule																																															
NEEDLE COUNT PADS FOAM STYLE  KENDALL	272	RC						Both			7.35	3.31	3.31	6.62	4.78							Fee Schedule		5.44							Fee Schedule																													6.62							Fee Schedule																																															
NEEDLE COUNT SET 10CT	272	RC						Both			2.1	0.95	0.95	1.89	1.37							Fee Schedule		1.55							Fee Schedule																													1.89							Fee Schedule																																															
NEEDLE COUNTER SET 30CT #DYNJNC30F	272	RC						Both			4	1.8	1.8	3.6	2.6							Fee Schedule		2.96							Fee Schedule																													3.6							Fee Schedule																																															
NEEDLE DELIVERY NORIAN INJ. DLS-7103-01S	272	RC						Both			279.3	125.69	125.69	251.37	181.55							Fee Schedule		206.68							Fee Schedule																													251.37							Fee Schedule																																															
NEEDLE EXPRESSEW #214141 DEPUY MITEK-J&J	272	RC						Both			1141	513.45	513.45	1026.9	741.65							Fee Schedule		844.34							Fee Schedule																													1026.9							Fee Schedule																																															
NEEDLE INJECTAK 35CM   DIS199 (DISC.)	272	RC						Both			233.1	104.9	104.9	209.79	151.52							Fee Schedule		172.49							Fee Schedule																													209.79							Fee Schedule																																															
NEEDLE INSERTION 3+ MUSCLES W/O INJECTI	761	RC	20561	CPT				Both			40	18	18	36	31.51							Fee Schedule		29.6							Fee Schedule																													36							Fee Schedule																																															
NEEDLE INTRODUCER 18X2.5 ( OR ) AN-04318	272	RC						Both			6.93	3.12	3.12	6.24	4.5							Fee Schedule		5.13							Fee Schedule																													6.24							Fee Schedule																																															
NEEDLE NON CORING 22G # 0602340 BARD	272	RC						Both			14.7	6.62	6.62	13.23	9.56							Fee Schedule		10.88							Fee Schedule																													13.23							Fee Schedule																																															
NEEDLES 25X1 B.D. INDUSTRIAL MEDICINE	272	RC						Both			3.15	1.42	1.42	2.84	2.05							Fee Schedule		2.33							Fee Schedule																													2.84							Fee Schedule																																															
NEFAZODONE 100MG (SERZONE) TABLET	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
NEO DECADRON OPTH SOLUTION	250	RC	A9270	CPT				Both			25.2	11.34	0.01	22.68	0.01							Fee Schedule		18.65							Fee Schedule																													22.68							Fee Schedule																																															
NEO SYN DROPS:1/8%	250	RC	A9270	CPT				Both			10.33	4.65	0.01	9.3	0.01							Fee Schedule		7.64							Fee Schedule																													9.3							Fee Schedule																																															
NEODECADRON OP .05%	250	RC	A9270	CPT				Both			18.21	8.19	0.01	16.39	0.01							Fee Schedule		13.48							Fee Schedule																													16.39							Fee Schedule																																															
NEOM/POLY B/HC (CORTISPORIN) OTIC SUSP	250	RC	A9270	CPT				Both			97.02	43.66	0.01	87.32	0.01							Fee Schedule		71.79							Fee Schedule																													87.32							Fee Schedule																																															
NEOM/POLY B/HC OPTHALMIC SUSP 7.5ML	250	RC	A9270	CPT				Both			255.56	115	0.01	230	0.01							Fee Schedule		189.11							Fee Schedule																													230							Fee Schedule																																															
NEOM/POLYM B/HC (CORTISPORIN) OTIC SOLN	250	RC	A9270	CPT				Both			97.02	43.66	0.01	87.32	0.01							Fee Schedule		71.79							Fee Schedule																													87.32							Fee Schedule																																															
NEOMY/POLYMIX/HC (CORTISPORIN) OPTH OINT	250	RC	A9270	CPT				Both			29.4	13.23	0.01	26.46	0.01							Fee Schedule		21.76							Fee Schedule																													26.46							Fee Schedule																																															
NEOMYCIN 500 MG TABLET	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
NEOMYCIN/ POLY/ BACITRACIN OPTH OINT	250	RC	A9270	CPT				Both			106.05	47.72	0.01	95.45	0.01							Fee Schedule		78.48							Fee Schedule																													95.45							Fee Schedule																																															
NEOMYCIN/ POLY/ DEX (MAXITROL) OPTH OINT	250	RC	A9270	CPT				Both			25.2	11.34	0.01	22.68	0.01							Fee Schedule		18.65							Fee Schedule																													22.68							Fee Schedule																																															
NEOMYCIN/ POLY/ DEX (MAXITROL) OPTH SUSP	250	RC	A9270	CPT				Both			59.57	26.81	0.01	53.61	0.01							Fee Schedule		44.08							Fee Schedule																													53.61							Fee Schedule																																															
NEOMYCIN/ POLY/ GRAMICIDIN OPTH SOL	250	RC	A9270	CPT				Both			94.5	42.53	0.01	85.05	0.01							Fee Schedule		69.93							Fee Schedule																													85.05							Fee Schedule																																															
NEOMYCIN/POLYMYXIN B  IRRIGANT 20ML MDV	250	RC	A9270	CPT				Both			739.2	332.64	0.01	665.28	0.01							Fee Schedule		547.01							Fee Schedule																													665.28							Fee Schedule																																															
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROC					517	DRG		Inpatient			36679.53	16505.79	16505.79	16505.79							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period	
HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WIT					522	DRG		Inpatient			64792.9	29156.81	29156.81	29156.81							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period							0		No services provided during 15 month lookback period				12654.33	12654.33	12654.33	1 through 10									0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period	
NEOPRENE ANKLE BR	274	RC	L1902	CPT				Both			39.9	17.96	17.96	97.22		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	29.53							Fee Schedule		97.22							Fee Schedule		70.75							Fee Schedule											35.91							Fee Schedule																																															
NEOPRENE KNEE BR	274	RC	L1820	CPT				Both			135.45	60.95	60.95	153.46		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	100.23							Fee Schedule		153.46							Fee Schedule		117.67							Fee Schedule		94.39							Fee Schedule		121.91							Fee Schedule		108.55							Fee Schedule		87.78							Fee Schedule											108.55							Fee Schedule		87.78							Fee Schedule		
NEOSPORIN OINT 1/32	250	RC	A9270	CPT				Both			1.58	0.71	0.01	171.34	0.01							Fee Schedule		1.17							Fee Schedule																				148.99							Fee Schedule		1.42							Fee Schedule		171.34							Fee Schedule		138.56							Fee Schedule											171.34							Fee Schedule		138.56							Fee Schedule		
NEOSPORIN OINT 30GM	250	RC	A9270	CPT				Both			16.41	7.38	0.01	14.77	0.01							Fee Schedule		12.14							Fee Schedule																													14.77							Fee Schedule																																															
NEOSTIGMINE 1MG/ML 10ML MDV 1:1000	636	RC	J2710	CPT				Both			10.08	4.54	0.88	9.07		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	7.46							Fee Schedule											0.88							Fee Schedule											9.07							Fee Schedule																																															
NEOSTIGMINE 1MG/ML-3ML SD SYRINGE	636	RC	J2710	CPT				Both			54	24.3	0.88	48.6		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	39.96							Fee Schedule											0.88							Fee Schedule											48.6							Fee Schedule																																															
NEO-SYNEPHRINE 0.25%(MILD) NASAL SPRAY	250	RC	A9270	CPT				Both			12.19	5.49	0.01	10.97	0.01							Fee Schedule		9.02							Fee Schedule																													10.97							Fee Schedule																																															
NEO-SYNEPHRINE 1%(XS) NASAL DROP- 15ML	250	RC	A9270	CPT				Both			13.67	6.15	0.01	12.3	0.01							Fee Schedule		10.12							Fee Schedule																													12.3							Fee Schedule																																															
NEO-SYNEPHRINE 1/2% NASAL DROPS-15ML	250	RC	A9270	CPT				Both			12.19	5.49	0.01	10.97	0.01							Fee Schedule		9.02							Fee Schedule																													10.97							Fee Schedule																																															
NEOSYNEPHRINE:10MG/CC	250	RC						Both			21	9.45	9.45	18.9	13.65							Fee Schedule		15.54							Fee Schedule																													18.9							Fee Schedule																																															
NEOTECH EZ-HOLD CANNULA HOLDER #N757 BIM	270	RC						Both			4	1.8	1.8	3.6	2.6							Fee Schedule		2.96							Fee Schedule																													3.6							Fee Schedule																																															
NEOTECH HYDROCOLLOID STRIPS #N741 BIMECO	270	RC						Both			6	2.7	2.7	5.4	3.9							Fee Schedule		4.44							Fee Schedule																													5.4							Fee Schedule																																															
NEOTECH NEOBAR ASSORTED #N719N BIMECO	270	RC						Both			29	13.05	13.05	26.1	18.85							Fee Schedule		21.46							Fee Schedule																													26.1							Fee Schedule																																															
NEOTECH NEOBAR LARGE #N713 BIMECO	270	RC						Both			30	13.5	13.5	27	19.5							Fee Schedule		22.2							Fee Schedule																													27							Fee Schedule																																															
NEOTECH NEOBAR MICRO #N711 BIMECO	270	RC						Both			30	13.5	13.5	27	19.5							Fee Schedule		22.2							Fee Schedule																													27							Fee Schedule																																															
NEOTECH NEOBAR MINI #N709 BIMECO	270	RC						Both			30	13.5	13.5	27	19.5							Fee Schedule		22.2							Fee Schedule																													27							Fee Schedule																																															
NEOTECH NEOBAR SMALL #N712 BIMECO	270	RC						Both			30	13.5	13.5	27	19.5							Fee Schedule		22.2							Fee Schedule																													27							Fee Schedule																																															
NEOTECH NEOBAR ULTRA #N710 BIMECO	270	RC						Both			59	26.55	26.55	53.1	38.35							Fee Schedule		43.66							Fee Schedule																													53.1							Fee Schedule																																															
NEOTECH NEOBAR XL LARGE #N714 BIMECO	270	RC						Both			30	13.5	13.5	27	19.5							Fee Schedule		22.2							Fee Schedule																													27							Fee Schedule																																															
NEOTECH NEOPULSE LG #N782 BIMECO	270	RC						Both			3	1.35	1.35	2.7	1.95							Fee Schedule		2.22							Fee Schedule																													2.7							Fee Schedule																																															
NEOTECH NEOPULSE SM #N781 BIMECO	270	RC						Both			3	1.35	1.35	2.7	1.95							Fee Schedule		2.22							Fee Schedule																													2.7							Fee Schedule																																															
NEOTECH RAM CANNULA INFANT N4903 BIMECO	272	RC	A4615	CPT				Both			32	14.4	0.66	28.8	0.66							Fee Schedule		23.68							Fee Schedule		1.07							Fee Schedule		0.82							Fee Schedule											28.8							Fee Schedule																																															
NEPHROSTOMY DRAINAGE BAG 600ML RMG600DBX	272	RC	A4357	CPT				Both			58	26.1	0.97	52.2	7.43							Fee Schedule		42.92							Fee Schedule		12.11							Fee Schedule		9.29							Fee Schedule		1.04							Fee Schedule		52.2							Fee Schedule		1.2							Fee Schedule		0.97							Fee Schedule											1.2							Fee Schedule		0.97							Fee Schedule		
NEPRO 240ML CAN	250	RC	B4154	CPT				Both			16.8	7.56	0.36	15.12	0.36							Fee Schedule		12.43							Fee Schedule											2.21							Fee Schedule		11.76							Fee Schedule		15.12							Fee Schedule		13.52							Fee Schedule		10.94							Fee Schedule											13.52							Fee Schedule		10.94							Fee Schedule		
NEPRO RTH 1000 ML	250	RC	B4154	CPT				Both			84	37.8	0.36	75.6	0.36							Fee Schedule		62.16							Fee Schedule											2.21							Fee Schedule											75.6							Fee Schedule																																															
NERVE BLOCK SUPPORT TRAY  33210	272	RC	A4550	CPT				Both			40	18	15.31	36.53	15.31							Fee Schedule		29.6							Fee Schedule											36.53							Fee Schedule											36							Fee Schedule																																															
NERVE INJECTION	370	RC	64400	CPT				Both			144.9	65.21	65.21	130.41	90.25							Fee Schedule		107.23							Fee Schedule																													130.41							Fee Schedule																																															
NERVE INJECTION	370	RC	64400	CPT				Both			144.9	65.21	65.21	130.41	90.25							Fee Schedule		107.23							Fee Schedule																													130.41							Fee Schedule																																															
NERVE LOCATOR #0003 (SENECA)	270	RC	E0275	CPT				Both			573.3	257.99	9.32	515.97	9.32							Fee Schedule		424.24							Fee Schedule		17.56							Fee Schedule																				515.97							Fee Schedule																																															
NERVE STIMULATOR	270	RC						Both			1140	513	15.86	1026	741							Fee Schedule		843.6							Fee Schedule																				17.05							Fee Schedule		1026							Fee Schedule		19.61							Fee Schedule		15.86							Fee Schedule											19.61							Fee Schedule		15.86							Fee Schedule		
NERVE TEASING PREPARATIONS	310	RC	88362	CPT				Both			687.75	309.49	63.09	618.98	63.09							Fee Schedule		87.4							Fee Schedule											106.74							Fee Schedule											618.98							Fee Schedule																																															
NERVOUS SYSTEM	370	RC	64999	CPT				Both			250	112.5	112.5	225	162.5							Fee Schedule		185							Fee Schedule																													225							Fee Schedule																																															
FRACTURES OF HIP AND PELVIS WITH MCC					535	DRG		Inpatient			50062.56	22528.15	22528.15	22528.15							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period	
NESACAINE 2% MPF 30 ML	636	RC	J2400	CPT				Both			72.92	32.81	32.81	65.63		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	53.96							Fee Schedule																													65.63							Fee Schedule																																															
NESACANE 2 BOTTLE	636	RC	J2400	CPT				Both			50.84	22.88	22.88	45.76		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	37.62							Fee Schedule																													45.76							Fee Schedule																																															
NESIRITIDE 1.5 MG/5ML VIAL	636	RC	J2325	CPT				Both			1889.48	850.27	850.27	1700.53		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1398.22							Fee Schedule																													1700.53							Fee Schedule																																															
NEULASTA PEGFILGRASTIM 6 MG/0.6ML SYRNG	636	RC	J2505	CPT				Both			21445.2	9650.34	9650.34	19300.68		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	15869.45							Fee Schedule																													19300.68							Fee Schedule																																															
NEUPOGEN 300 MCG/ML INJ	636	RC	J1442	CPT				Both			850.5	382.73	1.02	765.45		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1.02							Fee Schedule		1.03							Fee Schedule																				765.45							Fee Schedule																																															
NEUPOGEN 480 MCG/1.6 ML VIAL	636	RC	J1442	CPT				Both			1803	811.35	0.93	1622.7		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1.02							Fee Schedule		1.03							Fee Schedule											1							Fee Schedule		1622.7							Fee Schedule		1.15							Fee Schedule		0.93							Fee Schedule											1.15							Fee Schedule		0.93							Fee Schedule		
NEUROFILAMENT LIGHT CHAIN 13979	301	RC	83884	CPT				Both			810	364.5	0.93	729	526.5							Fee Schedule		116.23							Fee Schedule		119.72							Fee Schedule		116.23							Fee Schedule		1							Fee Schedule		729							Fee Schedule		1.15							Fee Schedule		0.93							Fee Schedule											1.15							Fee Schedule		0.93							Fee Schedule		
NEUROLON 0  #C527D	272	RC						Both			53.55	24.1	24.1	133.66	34.81							Fee Schedule		39.63							Fee Schedule																				116.23							Fee Schedule		48.2							Fee Schedule		133.66							Fee Schedule		108.09							Fee Schedule											133.66							Fee Schedule		108.09							Fee Schedule		
NEUROMYELITIS OPTICA 93893 1.0 ML SER FR	302	RC	86255	CPT				Both			708.75	318.94	10.71	637.88	10.71							Fee Schedule		13.39							Fee Schedule		12.41							Fee Schedule		12.05							Fee Schedule											637.88							Fee Schedule																				12.05							Fee Schedule																				
NEURON SPECIFIC ENOLASE 34476 SERUM	301	RC	86316	CPT				Both			147	66.15	11.21	132.3	18.5							Fee Schedule		23.13							Fee Schedule		21.43							Fee Schedule		20.81							Fee Schedule		12.05							Fee Schedule		132.3							Fee Schedule		13.86							Fee Schedule		11.21							Fee Schedule		20.81							Fee Schedule		13.86							Fee Schedule		11.21							Fee Schedule		
NEURON SPECIFIC ENOLASE 90520 CSF	301	RC	86316	CPT				Both			115.5	51.98	18.5	103.95	18.5							Fee Schedule		23.13							Fee Schedule		21.43							Fee Schedule		20.81							Fee Schedule		20.81							Fee Schedule		103.95							Fee Schedule		23.93							Fee Schedule		19.35							Fee Schedule		20.81							Fee Schedule		23.93							Fee Schedule		19.35							Fee Schedule		
NEUROSTIM CHARGING SYSTEM #1401	272	RC						Both			2700	1215	19.35	2430	1755							Fee Schedule		1998							Fee Schedule																				20.81							Fee Schedule		2430							Fee Schedule		23.93							Fee Schedule		19.35							Fee Schedule											23.93							Fee Schedule		19.35							Fee Schedule		
NEUROSTIM PT. REMOTE CONTROL #2301	272	RC						Both			2529	1138.05	1138.05	2276.1	1643.85							Fee Schedule		1871.46							Fee Schedule																													2276.1							Fee Schedule																																															
NEUROSTIM TINED LEAD IMPLANT KIT #1801	272	RC	C1894	CPT				Both			1035	465.75	87.34	931.5	87.34							Fee Schedule		765.9							Fee Schedule																													931.5							Fee Schedule																																															
NEUROSTIM TINED LEAD KIT # 1201	278	RC	C1778	CPT				Both			10053	4523.85	4523.85	9047.7		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	7439.22							Fee Schedule																													9047.7							Fee Schedule																																															
NEUROSTIMULATOR F15 #4101 RECHARGE-FREE	278	RC	C1767	CPT				Both			34953	15728.85	15728.85	31457.7		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	25865.22							Fee Schedule																													31457.7							Fee Schedule																																															
NEUROSTIMULATOR R20 #5101 RECHARGABLE	278	RC	C1820	CPT				Both			32253	14513.85	14513.85	29027.7		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	23867.22							Fee Schedule																													29027.7							Fee Schedule																																															
NEUTROPHIL FUNCTION 37523 SODIUM HEP	301	RC	82657	CPT				Both			147	66.15	16.05	132.3	16.05							Fee Schedule		22.17							Fee Schedule		22.84							Fee Schedule		22.17							Fee Schedule											132.3							Fee Schedule																				22.17							Fee Schedule																				
NEWBORN SECURITY BANDS 100908	270	RC						Both			23	10.35	10.35	25.5	14.95							Fee Schedule		17.02							Fee Schedule																				22.17							Fee Schedule		20.7							Fee Schedule		25.5							Fee Schedule		20.62							Fee Schedule											25.5							Fee Schedule		20.62							Fee Schedule		
NEWBORN URINE COLLECTOR	272	RC						Both			6.3	2.84	2.84	5.67	4.1							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
NEXIUM 40 MG VIALS	250	RC						Both			92.4	41.58	41.58	83.16	60.06							Fee Schedule		68.38							Fee Schedule																													83.16							Fee Schedule																																															
NF DR GUIDER DIAPER RASH CREAM	250	RC	A9270	CPT				Both			42.53	19.14	0.01	38.28	0.01							Fee Schedule		31.47							Fee Schedule																													38.28							Fee Schedule																																															
NF-Abilify Oral Tablet 15MG	250	RC						Both			70	31.5	31.5	63	45.5							Fee Schedule		51.8							Fee Schedule																													63							Fee Schedule																																															
NF-Accolate Oral Tablet 10MG	250	RC						Both			6	2.7	2.7	5.4	3.9							Fee Schedule		4.44							Fee Schedule																													5.4							Fee Schedule																																															
NF-Acetylcysteine Inhalation Solution 20	250	RC						Both			12	5.4	5.4	10.8	7.8							Fee Schedule		8.88							Fee Schedule																													10.8							Fee Schedule																																															
NF-Adderall Oral Tablet 20MG	250	RC						Both			42	18.9	18.9	37.8	27.3							Fee Schedule		31.08							Fee Schedule																													37.8							Fee Schedule																																															
NF-Adderall XR Oral Cap ER 25MG	250	RC						Both			25	11.25	11.25	22.5	16.25							Fee Schedule		18.5							Fee Schedule																													22.5							Fee Schedule																																															
NF-Adempas Oral Tablet 2.5MG	250	RC						Both			592	266.4	266.4	532.8	384.8							Fee Schedule		438.08							Fee Schedule																													532.8							Fee Schedule																																															
NF-Advair Diskus 250/50 Disk	250	RC						Both			11	4.95	4.95	9.9	7.15							Fee Schedule		8.14							Fee Schedule																													9.9							Fee Schedule																																															
NF-Albuterol Sulfate HFA Inh 0.09MG/1ACT	250	RC						Both			10	4.5	4.5	9	6.5							Fee Schedule		7.4							Fee Schedule																													9							Fee Schedule																																															
NF-Albuterol Sulfate HFA Inh 0.09MG/1ACT	250	RC						Both			10	4.5	4.5	9	6.5							Fee Schedule		7.4							Fee Schedule																													9							Fee Schedule																																															
NF-Alendronate Sod Oral Tablet 35MG	250	RC						Both			57	25.65	25.65	51.3	37.05							Fee Schedule		42.18							Fee Schedule																													51.3							Fee Schedule																																															
NF-Alfuzosin Hydrochloride Oral Tab ER 1	250	RC						Both			1	0.45	0.45	0.9	0.65							Fee Schedule		0.74							Fee Schedule																													0.9							Fee Schedule																																															
NF-Alfuzosin Hydrochloride Oral Tab ER 1	250	RC						Both			1	0.45	0.45	0.9	0.65							Fee Schedule		0.74							Fee Schedule																													0.9							Fee Schedule																																															
NF-Alfuzosin Hydrochloride Oral Tab ER 1	250	RC						Both			1	0.45	0.45	0.9	0.65							Fee Schedule		0.74							Fee Schedule																													0.9							Fee Schedule																																															
NF-Align Oral Capsule 4MG	250	RC						Both			2	0.9	0.9	1.8	1.3							Fee Schedule		1.48							Fee Schedule																													1.8							Fee Schedule																																															
"NF-Align Oral Tablet, Chewable 10.5MG"	250	RC						Both			3	1.35	1.35	2.7	1.95							Fee Schedule		2.22							Fee Schedule																													2.7							Fee Schedule																																															
NF-ALPRAZOLAM ORAL TABLET 1MG	250	RC						Both			2.67	1.2	1.2	2.4	1.74							Fee Schedule		1.98							Fee Schedule																													2.4							Fee Schedule																																															
NF-Ambien Oral Tablet 10MG	250	RC						Both			7	3.15	3.15	6.3	4.55							Fee Schedule		5.18							Fee Schedule																													6.3							Fee Schedule																																															
NF-amLODIPine Besylate Oral Tablet 10MG	250	RC						Both			7	3.15	3.15	6.3	4.55							Fee Schedule		5.18							Fee Schedule																													6.3							Fee Schedule																																															
NF-amLODIPine Besylate Oral Tablet 10MG	250	RC						Both			7	3.15	3.15	6.3	4.55							Fee Schedule		5.18							Fee Schedule																													6.3							Fee Schedule																																															
NF-amLODIPine Besylate Oral Tablet 10MG	250	RC						Both			7	3.15	3.15	6.3	4.55							Fee Schedule		5.18							Fee Schedule																													6.3							Fee Schedule																																															
NF-Anoro Ellipta Inhalation Powder	250	RC						Both			30	13.5	13.5	27	19.5							Fee Schedule		22.2							Fee Schedule																													27							Fee Schedule																																															
NF-Arformoterol Tartrate Inh Soln 15MCG/	250	RC						Both			32	14.4	14.4	28.8	20.8							Fee Schedule		23.68							Fee Schedule																													28.8							Fee Schedule																																															
NF-ARIPiprazole Oral Tablet 15MG*	250	RC						Both			96	43.2	43.2	86.4	62.4							Fee Schedule		71.04							Fee Schedule																													86.4							Fee Schedule																																															
NF-Asenapine Sublingual Tablet 10MG	250	RC						Both			67	30.15	30.15	60.3	43.55							Fee Schedule		49.58							Fee Schedule																													60.3							Fee Schedule																																															
NF-Atorvastatin Calcium Oral Tab 20MG	250	RC						Both			17	7.65	7.65	15.3	11.05							Fee Schedule		12.58							Fee Schedule																													15.3							Fee Schedule																																															
NF-Atorvastatin Calcium Oral Tab 80MG	250	RC						Both			17	7.65	7.65	15.3	11.05							Fee Schedule		12.58							Fee Schedule																													15.3							Fee Schedule																																															
NF-Austedo XR Oral Tab ER 24MG	250	RC						Both			900	405	405	810	585							Fee Schedule		666							Fee Schedule																													810							Fee Schedule																																															
NF-azaTHIOprine Oral Tablet 50MG	250	RC						Both			6	2.7	2.7	5.4	3.9							Fee Schedule		4.44							Fee Schedule																													5.4							Fee Schedule																																															
NF-azaTHIOprine Oral Tablet 50MG	250	RC						Both			2	0.9	0.9	1.8	1.3							Fee Schedule		1.48							Fee Schedule																													1.8							Fee Schedule																																															
NF-Baclofen Oral Tablet 5MG	250	RC						Both			3	1.35	1.35	2.7	1.95							Fee Schedule		2.22							Fee Schedule																													2.7							Fee Schedule																																															
NF-Basaglar KwikPen SubQ Soln 100U/1ML	250	RC						Both			78	35.1	35.1	70.2	50.7							Fee Schedule		57.72							Fee Schedule																													70.2							Fee Schedule																																															
NF-Bisacodyl Rectal Suppository 10MG	250	RC						Both			1	0.45	0.45	0.9	0.65							Fee Schedule		0.74							Fee Schedule																													0.9							Fee Schedule																																															
NF-Brenzavvy Oral Tablet 20MG	250	RC						Both			4	1.8	1.8	3.6	2.6							Fee Schedule		2.96							Fee Schedule																													3.6							Fee Schedule																																															
NF-Breyna Inh Aer Liq 160MCG-4.5MCG	250	RC						Both			129	58.05	58.05	116.1	83.85							Fee Schedule		95.46							Fee Schedule																													116.1							Fee Schedule																																															
NF-Breztri Aerosphere Inh Aer Liq	250	RC						Both			223	100.35	100.35	200.7	144.95							Fee Schedule		165.02							Fee Schedule																													200.7							Fee Schedule																																															
NF-Breztri Aerosphere Inh Aer Liq	250	RC						Both			223	100.35	100.35	200.7	144.95							Fee Schedule		165.02							Fee Schedule																													200.7							Fee Schedule																																															
NF-Breztri Aerosphere Inh Aer Liq	250	RC						Both			223	100.35	100.35	200.7	144.95							Fee Schedule		165.02							Fee Schedule																													200.7							Fee Schedule																																															
NF-Breztri Aerosphere Inh Aer Liq	250	RC						Both			230	103.5	103.5	207	149.5							Fee Schedule		170.2							Fee Schedule																													207							Fee Schedule																																															
NF-Brimonidine Tartrate Ophth Soln 0.2%	250	RC						Both			10	4.5	4.5	9	6.5							Fee Schedule		7.4							Fee Schedule																													9							Fee Schedule																																															
NF-Brimonidine Tartrate Ophth Soln 0.2%	250	RC						Both			10	4.5	4.5	9	6.5							Fee Schedule		7.4							Fee Schedule																													9							Fee Schedule																																															
NF-Briviact Oral Tablet 50MG	250	RC						Both			90	40.5	40.5	81	58.5							Fee Schedule		66.6							Fee Schedule																													81							Fee Schedule																																															
NF-Budesonide Delayed Release Capsule 3M	250	RC						Both			56	25.2	25.2	50.4	36.4							Fee Schedule		41.44							Fee Schedule																													50.4							Fee Schedule																																															
NF-Budesonide Delayed Release Capsule 3M	250	RC						Both			56	25.2	25.2	50.4	36.4							Fee Schedule		41.44							Fee Schedule																													50.4							Fee Schedule																																															
NF-Budesonide Oral Tablet ER 9MG	250	RC						Both			204	91.8	91.8	183.6	132.6							Fee Schedule		150.96							Fee Schedule																													183.6							Fee Schedule																																															
NF-Budesonide Oral Tablet ER 9MG	250	RC						Both			146	65.7	65.7	131.4	94.9							Fee Schedule		108.04							Fee Schedule																													131.4							Fee Schedule																																															
NF-Budesonide-Formoterol Fum 160/4.5	250	RC						Both			118	53.1	53.1	106.2	76.7							Fee Schedule		87.32							Fee Schedule																													106.2							Fee Schedule																																															
NF-Buprenorphine/Naloxone AvPak 8MG-2MG	250	RC						Both			25	11.25	11.25	22.5	16.25							Fee Schedule		18.5							Fee Schedule																													22.5							Fee Schedule																																															
NF-Buprenorphine/Naloxone SL Tab 2MG-0.5	250	RC						Both			31	13.95	13.95	27.9	20.15							Fee Schedule		22.94							Fee Schedule																													27.9							Fee Schedule																																															
NF-Buprenorphine/Naloxone SL Tab 2MG-0.5	250	RC						Both			31	13.95	13.95	27.9	20.15							Fee Schedule		22.94							Fee Schedule																													27.9							Fee Schedule																																															
NF-Buprenorphine/Naloxone SL Tab 2MG-0.5	250	RC						Both			31	13.95	13.95	27.9	20.15							Fee Schedule		22.94							Fee Schedule																													27.9							Fee Schedule																																															
NF-Buprenorphine-Naloxone SL Film 8MG-2M	250	RC						Both			26	11.7	11.7	23.4	16.9							Fee Schedule		19.24							Fee Schedule																													23.4							Fee Schedule																																															
NF-Buprenorphine-Naloxone SL Film 8MG-2M	250	RC						Both			26	11.7	11.7	23.4	16.9							Fee Schedule		19.24							Fee Schedule																													23.4							Fee Schedule																																															
NF-Buprenorphine-Naloxone SL Film 8MG-2M	250	RC						Both			26	11.7	11.7	23.4	16.9							Fee Schedule		19.24							Fee Schedule																													23.4							Fee Schedule																																															
NF-buPROPion HCl Oral Tablet SR 100MG	250	RC						Both			5	2.25	2.25	4.5	3.25							Fee Schedule		3.7							Fee Schedule																													4.5							Fee Schedule																																															
"NF-buPROPion HCl Tab ER, 12HR 200MG"	250	RC						Both			11	4.95	4.95	9.9	7.15							Fee Schedule		8.14							Fee Schedule																													9.9							Fee Schedule																																															
NF-busPIRone Oral Tablet 30MG	250	RC						Both			10	4.5	4.5	9	6.5							Fee Schedule		7.4							Fee Schedule																													9							Fee Schedule																																															
NF-Camzyos Oral Capsule 2.5MG	250	RC						Both			1027	462.15	462.15	924.3	667.55							Fee Schedule		759.98							Fee Schedule																													924.3							Fee Schedule																																															
NF-Caplyta Oral Capsule 42MG	250	RC						Both			199	89.55	89.55	179.1	129.35							Fee Schedule		147.26							Fee Schedule																													179.1							Fee Schedule																																															
NF-carBAMazepine Oral Tablet ER 100MG	250	RC						Both			3	1.35	1.35	2.7	1.95							Fee Schedule		2.22							Fee Schedule																													2.7							Fee Schedule																																															
NF-Carboxymethylcelull Sod Ophth Soln 0.	250	RC						Both			1	0.45	0.45	0.9	0.65							Fee Schedule		0.74							Fee Schedule																													0.9							Fee Schedule																																															
NF-Carboxymethylcelull Sod Ophth Soln 0.	250	RC						Both			1	0.45	0.45	0.9	0.65							Fee Schedule		0.74							Fee Schedule																													0.9							Fee Schedule																																															
NF-Carvedilol Oral Capsule ER 20MG	250	RC						Both			30	13.5	13.5	27	19.5							Fee Schedule		22.2							Fee Schedule																													27							Fee Schedule																																															
NF-Carvedilol Oral Tablet 6.25MG	250	RC						Both			6	2.7	2.7	5.4	3.9							Fee Schedule		4.44							Fee Schedule																													5.4							Fee Schedule																																															
NF-Cialis Tablet 10MG	250	RC						Both			202	90.9	90.9	181.8	131.3							Fee Schedule		149.48							Fee Schedule																													181.8							Fee Schedule																																															
NF-Ciclopirox Topical Solution 8%	250	RC						Both			77	34.65	34.65	69.3	50.05							Fee Schedule		56.98							Fee Schedule																													69.3							Fee Schedule																																															
NF-Cimetidine Oral Tablet 300MG	250	RC						Both			2	0.9	0.9	1.8	1.3							Fee Schedule		1.48							Fee Schedule																													1.8							Fee Schedule																																															
NF-Citalopram Oral Tablet 40MG	250	RC						Both			7	3.15	3.15	6.3	4.55							Fee Schedule		5.18							Fee Schedule																													6.3							Fee Schedule																																															
NF-Cleocin T Topical Gel 1%	250	RC						Both			11	4.95	4.95	9.9	7.15							Fee Schedule		8.14							Fee Schedule																													9.9							Fee Schedule																																															
NF-CLINDAMYCIN PHOSPHATE GEL 1%	250	RC						Both			10.37	4.67	4.67	9.33	6.74							Fee Schedule		7.67							Fee Schedule																													9.33							Fee Schedule																																															
NF-Clobetasol Propionate Shampoo 0.05%	250	RC						Both			9	4.05	4.05	8.1	5.85							Fee Schedule		6.66							Fee Schedule																													8.1							Fee Schedule																																															
NF-Clobetasol Propionate Solution 0.05%	250	RC						Both			12	5.4	5.4	10.8	7.8							Fee Schedule		8.88							Fee Schedule																													10.8							Fee Schedule																																															
NF-clomiPRAMINE HCl Capsule 25MG	250	RC						Both			33	14.85	14.85	29.7	21.45							Fee Schedule		24.42							Fee Schedule																													29.7							Fee Schedule																																															
NF-cloZAPine Oral Tablet 200MG	250	RC						Both			18	8.1	8.1	16.2	11.7							Fee Schedule		13.32							Fee Schedule																													16.2							Fee Schedule																																															
NF-Co Q10 Oral Liquid Capsule 100MG	250	RC						Both			1	0.45	0.45	0.9	0.65							Fee Schedule		0.74							Fee Schedule																													0.9							Fee Schedule																																															
NF-Cobenfy Oral Capsule 50MG-20MG	250	RC						Both			111	49.95	49.95	99.9	72.15							Fee Schedule		82.14							Fee Schedule																													99.9							Fee Schedule																																															
NF-Concerta Extended-Release Tablet 36MG	250	RC						Both			13	5.85	5.85	11.7	8.45							Fee Schedule		9.62							Fee Schedule																													11.7							Fee Schedule																																															
NF-CONCERTA EXTENDED-RELEASE TABLET 54MG	250	RC						Both			14.72	6.62	6.62	13.25	9.57							Fee Schedule		10.89							Fee Schedule																													13.25							Fee Schedule																																															
NF-Co-Q10 Oral Capsule 100MG	250	RC						Both			1	0.45	0.45	0.9	0.65							Fee Schedule		0.74							Fee Schedule																													0.9							Fee Schedule																																															
NF-Cosopt Ophth Solution 2%/0.5%	250	RC						Both			87	39.15	39.15	78.3	56.55							Fee Schedule		64.38							Fee Schedule																													78.3							Fee Schedule																																															
NF-Cyclobenzaprine Oral Tablet 10MG	250	RC						Both			6	2.7	2.7	5.4	3.9							Fee Schedule		4.44							Fee Schedule																													5.4							Fee Schedule																																															
NF-Dapagliflozin Oral Tablet 5MG	250	RC						Both			66	29.7	29.7	59.4	42.9							Fee Schedule		48.84							Fee Schedule																													59.4							Fee Schedule																																															
NF-Depakote Delayed-Release Tablet 500MG	250	RC						Both			25	11.25	11.25	22.5	16.25							Fee Schedule		18.5							Fee Schedule																													22.5							Fee Schedule																																															
NF-Depakote Oral Tab DR 125MG	250	RC						Both			7	3.15	3.15	6.3	4.55							Fee Schedule		5.18							Fee Schedule																													6.3							Fee Schedule																																															
NF-Desvenlafaxine Succinate Tab ER 100MG	250	RC						Both			34	15.3	15.3	30.6	22.1							Fee Schedule		25.16							Fee Schedule																													30.6							Fee Schedule																																															
NF-DESVENLAFAXINE SUCCINATE TAB ER 50MG	250	RC						Both			35.85	16.13	16.13	32.27	23.3							Fee Schedule		26.53							Fee Schedule																													32.27							Fee Schedule																																															
NF-Dexcom G7 Sensor Device	250	RC						Both			470	211.5	211.5	423	305.5							Fee Schedule		347.8							Fee Schedule																													423							Fee Schedule																																															
NF-Diclofenac Potassium Tablet 50MG	250	RC						Both			4	1.8	1.8	3.6	2.6							Fee Schedule		2.96							Fee Schedule																													3.6							Fee Schedule																																															
NF-Dilantin Extended Release Capsule 30M	250	RC						Both			5	2.25	2.25	4.5	3.25							Fee Schedule		3.7							Fee Schedule																													4.5							Fee Schedule																																															
NF-Docusate Oral Capsule LiquidFilled 10	250	RC						Both			1	0.45	0.45	0.9	0.65							Fee Schedule		0.74							Fee Schedule																													0.9							Fee Schedule																																															
NF-Donepezil Hydrochloride Oral Tablet 2	250	RC						Both			34	15.3	15.3	30.6	22.1							Fee Schedule		25.16							Fee Schedule																													30.6							Fee Schedule																																															
NF-Dorzolamide HCl-Timolol Ophth Soln	250	RC						Both			8	3.6	3.6	7.2	5.2							Fee Schedule		5.92							Fee Schedule																													7.2							Fee Schedule																																															
NF-Dorzolamide Hydrochloride Ophth Soln	250	RC						Both			20	9	9	18	13							Fee Schedule		14.8							Fee Schedule																													18							Fee Schedule																																															
NF-Dorzolamide Hydrochloride Ophth Soln	250	RC						Both			20	9	9	18	13							Fee Schedule		14.8							Fee Schedule																													18							Fee Schedule																																															
NF-Dorzolamide Hydrochloride Ophth Soln	250	RC						Both			20	9	9	18	13							Fee Schedule		14.8							Fee Schedule																													18							Fee Schedule																																															
NF-Doxepin Oral Tablet 3MG	250	RC						Both			51	22.95	22.95	45.9	33.15							Fee Schedule		37.74							Fee Schedule																													45.9							Fee Schedule																																															
NF-Doxepin Oral Tablet 3MG	250	RC						Both			51	22.95	22.95	45.9	33.15							Fee Schedule		37.74							Fee Schedule																													45.9							Fee Schedule																																															
NF-Doxycycline Monohydrate Capsule 100MG	250	RC						Both			7	3.15	3.15	6.3	4.55							Fee Schedule		5.18							Fee Schedule																													6.3							Fee Schedule																																															
NF-Drisdol Oral LiquidFilledCapsule 5000	250	RC						Both			10	4.5	4.5	9	6.5							Fee Schedule		7.4							Fee Schedule																													9							Fee Schedule																																															
NF-Droxidopa Oral Capsule 100MG	250	RC						Both			69	31.05	31.05	62.1	44.85							Fee Schedule		51.06							Fee Schedule																													62.1							Fee Schedule																																															
NF-Dulera Inh Aer Pwd 5MCG-100MCG/Act	250	RC						Both			94	42.3	42.3	84.6	61.1							Fee Schedule		69.56							Fee Schedule																													84.6							Fee Schedule																																															
NF-Dulera Inh Aer Pwd 5MCG-200MCG/Act	250	RC						Both			94	42.3	42.3	84.6	61.1							Fee Schedule		69.56							Fee Schedule																													84.6							Fee Schedule																																															
NF-DULoxetine HCl Cap DR 60MG	250	RC						Both			23	10.35	10.35	20.7	14.95							Fee Schedule		17.02							Fee Schedule																													20.7							Fee Schedule																																															
NF-Effer-K Oral Tab Eff 20MEQ	250	RC						Both			1	0.45	0.45	0.9	0.65							Fee Schedule		0.74							Fee Schedule																													0.9							Fee Schedule																																															
NF-Effexor-XR Capsule 150MG	250	RC						Both			55	24.75	24.75	49.5	35.75							Fee Schedule		40.7							Fee Schedule																													49.5							Fee Schedule																																															
NF-Eletriptan HBr Oral Tablet 40MG	250	RC						Both			184	82.8	82.8	165.6	119.6							Fee Schedule		136.16							Fee Schedule																													165.6							Fee Schedule																																															
NF-Entacapone Oral Tablet 200MG	250	RC						Both			11	4.95	4.95	9.9	7.15							Fee Schedule		8.14							Fee Schedule																													9.9							Fee Schedule																																															
NF-Entresto Oral Tablet 97MG-103MG	250	RC						Both			27	12.15	12.15	24.3	17.55							Fee Schedule		19.98							Fee Schedule																													24.3							Fee Schedule																																															
NF-Entresto Oral Tablet 97MG-103MG	250	RC						Both			43	19.35	19.35	38.7	27.95							Fee Schedule		31.82							Fee Schedule																													38.7							Fee Schedule																																															
NF-Entresto Oral Tablet 97MG-103MG	250	RC						Both			43	19.35	19.35	38.7	27.95							Fee Schedule		31.82							Fee Schedule																													38.7							Fee Schedule																																															
NF-Eplerenone Oral Tablet 25MG	250	RC						Both			13	5.85	5.85	11.7	8.45							Fee Schedule		9.62							Fee Schedule																													11.7							Fee Schedule																																															
NF-Eplerenone Oral Tablet 25MG	250	RC						Both			13	5.85	5.85	11.7	8.45							Fee Schedule		9.62							Fee Schedule																													11.7							Fee Schedule																																															
NF-Eplerenone Oral Tablet 50MG	250	RC						Both			13	5.85	5.85	11.7	8.45							Fee Schedule		9.62							Fee Schedule																													11.7							Fee Schedule																																															
NF-Erleada Oral Tablet 60MG	250	RC						Both			459	206.55	206.55	413.1	298.35							Fee Schedule		339.66							Fee Schedule																													413.1							Fee Schedule																																															
NF-Esomeprazole Magnesium Oral Cap DR 20	250	RC						Both			25	11.25	11.25	22.5	16.25							Fee Schedule		18.5							Fee Schedule																													22.5							Fee Schedule																																															
NF-Estazolam Tablet 2MG	250	RC						Both			2	0.9	0.9	1.8	1.3							Fee Schedule		1.48							Fee Schedule																													1.8							Fee Schedule																																															
NF-Estradiol TD Patch ER 0.05MG/24HR	250	RC						Both			48	21.6	21.6	43.2	31.2							Fee Schedule		35.52							Fee Schedule																													43.2							Fee Schedule																																															
NF-ESTRADIOL TD PATCH ER 0.05MG/24HR	250	RC						Both			68.67	30.9	30.9	61.8	44.64							Fee Schedule		50.82							Fee Schedule																													61.8							Fee Schedule																																															
NF-ESTRADIOL TD PATCH ER 0.05MG/24HR	250	RC						Both			68.67	30.9	30.9	61.8	44.64							Fee Schedule		50.82							Fee Schedule																													61.8							Fee Schedule																																															
NF-Estradiol Vaginal Cream 0.1MG/1GM	250	RC						Both			21	9.45	9.45	18.9	13.65							Fee Schedule		15.54							Fee Schedule																													18.9							Fee Schedule																																															
NF-Estradiol Vaginal Cream 0.1MG/1GM	250	RC						Both			21	9.45	9.45	18.9	13.65							Fee Schedule		15.54							Fee Schedule																													18.9							Fee Schedule																																															
NF-EstradiolTD Patch ER 0.0375MG/24HR	250	RC						Both			8	3.6	3.6	7.2	5.2							Fee Schedule		5.92							Fee Schedule																													7.2							Fee Schedule																																															
NF-eszopiclone Oral Tablet 3MG	250	RC						Both			34	15.3	15.3	30.6	22.1							Fee Schedule		25.16							Fee Schedule																													30.6							Fee Schedule																																															
NF-Etodolac Capsule 300MG	250	RC						Both			4	1.8	1.8	3.6	2.6							Fee Schedule		2.96							Fee Schedule																													3.6							Fee Schedule																																															
NF-Famotidine Oral Tablet 20MG	250	RC						Both			7	3.15	3.15	6.3	4.55							Fee Schedule		5.18							Fee Schedule																													6.3							Fee Schedule																																															
NF-Famotidine Oral Tablet 40MG	250	RC						Both			14	6.3	6.3	12.6	9.1							Fee Schedule		10.36							Fee Schedule																													12.6							Fee Schedule																																															
NF-Farxiga Oral Tablet 10MG	250	RC						Both			37	16.65	16.65	33.3	24.05							Fee Schedule		27.38							Fee Schedule																													33.3							Fee Schedule																																															
NF-Farxiga Oral Tablet 10MG	250	RC						Both			37	16.65	16.65	33.3	24.05							Fee Schedule		27.38							Fee Schedule																													33.3							Fee Schedule																																															
NF-Farxiga Oral Tablet 10MG	250	RC						Both			37	16.65	16.65	33.3	24.05							Fee Schedule		27.38							Fee Schedule																													33.3							Fee Schedule																																															
NF-Farxiga Oral Tablet 10MG	250	RC						Both			37	16.65	16.65	33.3	24.05							Fee Schedule		27.38							Fee Schedule																													33.3							Fee Schedule																																															
NF-Farxiga Oral Tablet 10MG	250	RC						Both			37	16.65	16.65	33.3	24.05							Fee Schedule		27.38							Fee Schedule																													33.3							Fee Schedule																																															
NF-Farxiga Oral Tablet 10MG	250	RC						Both			37	16.65	16.65	33.3	24.05							Fee Schedule		27.38							Fee Schedule																													33.3							Fee Schedule																																															
NF-Farxiga Oral Tablet 10MG	250	RC						Both			37	16.65	16.65	33.3	24.05							Fee Schedule		27.38							Fee Schedule																													33.3							Fee Schedule																																															
NF-Farxiga Oral Tablet 10MG	250	RC						Both			37	16.65	16.65	33.3	24.05							Fee Schedule		27.38							Fee Schedule																													33.3							Fee Schedule																																															
NF-Farxiga Oral Tablet 10MG	250	RC						Both			45	20.25	20.25	40.5	29.25							Fee Schedule		33.3							Fee Schedule																													40.5							Fee Schedule																																															
NF-FARXIGA ORAL TABLET 5MG	250	RC						Both			69.87	31.44	31.44	62.88	45.42							Fee Schedule		51.7							Fee Schedule																													62.88							Fee Schedule																																															
NF-Farxiga Oral Tablet 5MG	250	RC						Both			37	16.65	16.65	33.3	24.05							Fee Schedule		27.38							Fee Schedule																													33.3							Fee Schedule																																															
NF-Farxiga Oral Tablet 5MG	250	RC						Both			37	16.65	16.65	33.3	24.05							Fee Schedule		27.38							Fee Schedule																													33.3							Fee Schedule																																															
NF-Farxiga Oral Tablet 5MG	250	RC						Both			37	16.65	16.65	33.3	24.05							Fee Schedule		27.38							Fee Schedule																													33.3							Fee Schedule																																															
NF-Femara Tablet 2.5MG	250	RC						Both			100	45	45	90	65							Fee Schedule		74							Fee Schedule																													90							Fee Schedule																																															
NF-Fenofibrate Oral Capsule 134MG	250	RC						Both			5	2.25	2.25	4.5	3.25							Fee Schedule		3.7							Fee Schedule																													4.5							Fee Schedule																																															
NF-Fenofibrate Oral Tablet 145MG	250	RC						Both			17	7.65	7.65	15.3	11.05							Fee Schedule		12.58							Fee Schedule																													15.3							Fee Schedule																																															
NF-fentaNYL Transdermal Patch ER 12MCG/H	250	RC						Both			60	27	27	54	39							Fee Schedule		44.4							Fee Schedule																													54							Fee Schedule																																															
NF-Fetzima Capsule Extended Release 120M	250	RC						Both			60	27	27	54	39							Fee Schedule		44.4							Fee Schedule																													54							Fee Schedule																																															
NF-Fexofenadine Hydrochloride Tablet 180	250	RC						Both			7	3.15	3.15	6.3	4.55							Fee Schedule		5.18							Fee Schedule																													6.3							Fee Schedule																																															
NF-Fexofenadine Hydrochloride Tablet 180	250	RC						Both			7	3.15	3.15	6.3	4.55							Fee Schedule		5.18							Fee Schedule																													6.3							Fee Schedule																																															
NF-fluPHENAZine HCl Oral Tablet 10MG	250	RC						Both			18	8.1	8.1	16.2	11.7							Fee Schedule		13.32							Fee Schedule																													16.2							Fee Schedule																																															
NF-Fluticasone Furoate Inh Pwd 50MCG/1AC	250	RC						Both			23	10.35	10.35	20.7	14.95							Fee Schedule		17.02							Fee Schedule																													20.7							Fee Schedule																																															
NF-Fluticasone Propionate 44MCG/1Act	250	RC						Both			65	29.25	29.25	58.5	42.25							Fee Schedule		48.1							Fee Schedule																													58.5							Fee Schedule																																															
NF-Folate Forte Tablet	250	RC						Both			3	1.35	1.35	2.7	1.95							Fee Schedule		2.22							Fee Schedule																													2.7							Fee Schedule																																															
NF-Formoterol Fumarate Inh Soln 20MCG/2M	250	RC						Both			31	13.95	13.95	27.9	20.15							Fee Schedule		22.94							Fee Schedule																													27.9							Fee Schedule																																															
NF-Fycompa Oral Tablet 6MG	250	RC						Both			147	66.15	66.15	132.3	95.55							Fee Schedule		108.78							Fee Schedule																													132.3							Fee Schedule																																															
NF-Gabapentin Oral Capsule 100MG	250	RC						Both			1	0.45	0.45	0.9	0.65							Fee Schedule		0.74							Fee Schedule																													0.9							Fee Schedule																																															
NF-Gabapentin Oral Capsule 300MG	250	RC						Both			3	1.35	1.35	2.7	1.95							Fee Schedule		2.22							Fee Schedule																													2.7							Fee Schedule																																															
NF-Galantamine HBr Oral Cap ER 24MG	250	RC						Both			18	8.1	8.1	16.2	11.7							Fee Schedule		13.32							Fee Schedule																													16.2							Fee Schedule																																															
NF-Gemtesa Oral Tablet 75MG	250	RC						Both			58	26.1	26.1	52.2	37.7							Fee Schedule		42.92							Fee Schedule																													52.2							Fee Schedule																																															
NF-Genvoya Oral Tablet	250	RC						Both			505	227.25	227.25	454.5	328.25							Fee Schedule		373.7							Fee Schedule																													454.5							Fee Schedule																																															
NF-Glipizide Oral Tablet 2.5MG	250	RC						Both			5	2.25	2.25	4.5	3.25							Fee Schedule		3.7							Fee Schedule																													4.5							Fee Schedule																																															
NF-glipiZIDE Oral Tablet ER 2.5MG	250	RC						Both			1	0.45	0.45	0.9	0.65							Fee Schedule		0.74							Fee Schedule																													0.9							Fee Schedule																																															
NF-Glutose 15 Gel 40%	250	RC						Both			12	5.4	5.4	10.8	7.8							Fee Schedule		8.88							Fee Schedule																													10.8							Fee Schedule																																															
NF-Haloperidol Tablet 1MG	250	RC						Both			1	0.45	0.45	0.9	0.65							Fee Schedule		0.74							Fee Schedule																													0.9							Fee Schedule																																															
NF-hydrALAZINE HCl Tab 50MG	250	RC						Both			1	0.45	0.45	0.9	0.65							Fee Schedule		0.74							Fee Schedule																													0.9							Fee Schedule																																															
NF-Hydrocortisone Oral Tablet 10MG	250	RC						Both			1	0.45	0.45	0.9	0.65							Fee Schedule		0.74							Fee Schedule																													0.9							Fee Schedule																																															
NF-Hydrocortisone Oral Tablet 5MG	250	RC						Both			1	0.45	0.45	0.9	0.65							Fee Schedule		0.74							Fee Schedule																													0.9							Fee Schedule																																															
NF-HYDROmorphone HCl Tablet 4MG	250	RC						Both			2	0.9	0.9	1.8	1.3							Fee Schedule		1.48							Fee Schedule																													1.8							Fee Schedule																																															
NF-HydrOXYzine HCl Tablet 50MG	250	RC						Both			3	1.35	1.35	2.7	1.95							Fee Schedule		2.22							Fee Schedule																													2.7							Fee Schedule																																															
NF-hydrOXYzine Pamoate Capsule 100MG	250	RC						Both			3	1.35	1.35	2.7	1.95							Fee Schedule		2.22							Fee Schedule																													2.7							Fee Schedule																																															
NF-Ilevro Ophthalmic Suspension 0.3%	250	RC						Both			456	205.2	205.2	410.4	296.4							Fee Schedule		337.44							Fee Schedule																													410.4							Fee Schedule																																															
NF-Ilevro Ophthalmic Suspension 0.3%	250	RC						Both			456	205.2	205.2	410.4	296.4							Fee Schedule		337.44							Fee Schedule																													410.4							Fee Schedule																																															
NF-INGREZZA ORAL CAPSULE 40MG	250	RC						Both			932.4	419.58	419.58	839.16	606.06							Fee Schedule		689.98							Fee Schedule																													839.16							Fee Schedule																																															
NF-Invega Sustenna IM Susp ER 234MG	250	RC						Both			8565	3854.25	3854.25	7708.5	5567.25							Fee Schedule		6338.1							Fee Schedule																													7708.5							Fee Schedule																																															
NF-Irbesartan Oral Tablet 300MG	250	RC						Both			11	4.95	4.95	9.9	7.15							Fee Schedule		8.14							Fee Schedule																													9.9							Fee Schedule																																															
NF-Irbesartan Oral Tablet 300MG	250	RC						Both			11	4.95	4.95	9.9	7.15							Fee Schedule		8.14							Fee Schedule																													9.9							Fee Schedule																																															
NF-Jardiance Oral Tablet 10MG	250	RC						Both			73	32.85	32.85	65.7	47.45							Fee Schedule		54.02							Fee Schedule																													65.7							Fee Schedule																																															
NF-Jardiance Oral Tablet 10MG	250	RC						Both			75	33.75	33.75	67.5	48.75							Fee Schedule		55.5							Fee Schedule																													67.5							Fee Schedule																																															
NF-Jardiance Oral Tablet 10MG	250	RC						Both			75	33.75	33.75	67.5	48.75							Fee Schedule		55.5							Fee Schedule																													67.5							Fee Schedule																																															
NF-Jardiance Oral Tablet 10MG	250	RC						Both			75	33.75	33.75	67.5	48.75							Fee Schedule		55.5							Fee Schedule																													67.5							Fee Schedule																																															
NF-Jardiance Oral Tablet 10MG	250	RC						Both			75	33.75	33.75	67.5	48.75							Fee Schedule		55.5							Fee Schedule																													67.5							Fee Schedule																																															
NF-Jardiance Oral Tablet 10MG	250	RC						Both			75	33.75	33.75	67.5	48.75							Fee Schedule		55.5							Fee Schedule																													67.5							Fee Schedule																																															
NF-Jardiance Oral Tablet 10MG	250	RC						Both			75	33.75	33.75	67.5	48.75							Fee Schedule		55.5							Fee Schedule																													67.5							Fee Schedule																																															
NF-Jardiance Oral Tablet 10MG	250	RC						Both			75	33.75	33.75	67.5	48.75							Fee Schedule		55.5							Fee Schedule																													67.5							Fee Schedule																																															
NF-Jardiance Oral Tablet 10MG	250	RC						Both			73	32.85	32.85	65.7	47.45							Fee Schedule		54.02							Fee Schedule																													65.7							Fee Schedule																																															
NF-Jardiance Oral Tablet 10MG	250	RC						Both			73	32.85	32.85	65.7	47.45							Fee Schedule		54.02							Fee Schedule																													65.7							Fee Schedule																																															
NF-Jardiance Oral Tablet 25MG	250	RC						Both			75	33.75	33.75	67.5	48.75							Fee Schedule		55.5							Fee Schedule																													67.5							Fee Schedule																																															
NF-Jardiance Oral Tablet 25MG	250	RC						Both			75	33.75	33.75	67.5	48.75							Fee Schedule		55.5							Fee Schedule																													67.5							Fee Schedule																																															
NF-Jardiance Oral Tablet 25MG	250	RC						Both			73	32.85	32.85	65.7	47.45							Fee Schedule		54.02							Fee Schedule																													65.7							Fee Schedule																																															
NF-Keppra Oral Tablet 1000MG	250	RC						Both			72	32.4	32.4	64.8	46.8							Fee Schedule		53.28							Fee Schedule																													64.8							Fee Schedule																																															
NF-Keppra Oral Tablet 1000MG	250	RC						Both			72	32.4	32.4	64.8	46.8							Fee Schedule		53.28							Fee Schedule																													64.8							Fee Schedule																																															
NF-Keppra XR Oral Tablet ER 500MG	250	RC						Both			33	14.85	14.85	29.7	21.45							Fee Schedule		24.42							Fee Schedule																													29.7							Fee Schedule																																															
NF-Lacosamide Oral Solution 10MG/1ML	250	RC						Both			6	2.7	2.7	5.4	3.9							Fee Schedule		4.44							Fee Schedule																													5.4							Fee Schedule																																															
NF-Lacosamide Oral Tablet 50MG	250	RC						Both			32	14.4	14.4	28.8	20.8							Fee Schedule		23.68							Fee Schedule																													28.8							Fee Schedule																																															
NF-lamoTRIgine Oral Tablet 150MG	250	RC						Both			16	7.2	7.2	14.4	10.4							Fee Schedule		11.84							Fee Schedule																													14.4							Fee Schedule																																															
NF-Lantus SoloStar SubQ Solution 100U/1M	250	RC						Both			54	24.3	24.3	48.6	35.1							Fee Schedule		39.96							Fee Schedule																													48.6							Fee Schedule																																															
NF-Lasix Tablet 20MG	250	RC						Both			2	0.9	0.9	1.8	1.3							Fee Schedule		1.48							Fee Schedule																													1.8							Fee Schedule																																															
NF-Latuda Oral Tablet 60MG	250	RC						Both			170	76.5	76.5	153	110.5							Fee Schedule		125.8							Fee Schedule																													153							Fee Schedule																																															
NF-Leflunomide Oral Tablet 20MG	250	RC						Both			49	22.05	22.05	44.1	31.85							Fee Schedule		36.26							Fee Schedule																													44.1							Fee Schedule																																															
NF-Letrozole Oral Tablet 2.5MG	250	RC						Both			54	24.3	24.3	48.6	35.1							Fee Schedule		39.96							Fee Schedule																													48.6							Fee Schedule																																															
NF-levETIRAcetam Oral Tablet 750MG	250	RC						Both			14	6.3	6.3	12.6	9.1							Fee Schedule		10.36							Fee Schedule																													12.6							Fee Schedule																																															
NF-levETIRAcetam Oral Tablet 750MG	250	RC						Both			14	6.3	6.3	12.6	9.1							Fee Schedule		10.36							Fee Schedule																													12.6							Fee Schedule																																															
NF-levETIRAcetam Oral Tablet 750MG	250	RC						Both			14	6.3	6.3	12.6	9.1							Fee Schedule		10.36							Fee Schedule																													12.6							Fee Schedule																																															
NF-levETIRAcetam Oral Tablet 750MG	250	RC						Both			14	6.3	6.3	12.6	9.1							Fee Schedule		10.36							Fee Schedule																													12.6							Fee Schedule																																															
NF-levETIRAcetam Oral Tablet 750MG	250	RC						Both			14	6.3	6.3	12.6	9.1							Fee Schedule		10.36							Fee Schedule																													12.6							Fee Schedule																																															
NF-levETIRAcetam Oral Tablet 750MG	250	RC						Both			14	6.3	6.3	12.6	9.1							Fee Schedule		10.36							Fee Schedule																													12.6							Fee Schedule																																															
NF-levETIRAcetam Oral Tablet 750MG	250	RC						Both			14	6.3	6.3	12.6	9.1							Fee Schedule		10.36							Fee Schedule																													12.6							Fee Schedule																																															
NF-Levothyroxine Oral Tablet 200MCG	250	RC						Both			1	0.45	0.45	0.9	0.65							Fee Schedule		0.74							Fee Schedule																													0.9							Fee Schedule																																															
NF-Levothyroxine Sodium Oral Tablet 200M	250	RC						Both			2	0.9	0.9	1.8	1.3							Fee Schedule		1.48							Fee Schedule																													1.8							Fee Schedule																																															
NF-Levothyroxine Sodium Oral Tablet 88MC	250	RC						Both			1	0.45	0.45	0.9	0.65							Fee Schedule		0.74							Fee Schedule																													0.9							Fee Schedule																																															
NF-Lidocaine Rectal Cream 5%	250	RC						Both			1	0.45	0.45	0.9	0.65							Fee Schedule		0.74							Fee Schedule																													0.9							Fee Schedule																																															
NF-Lidocaine Topical Patch ER 4%	250	RC						Both			19	8.55	8.55	17.1	12.35							Fee Schedule		14.06							Fee Schedule																													17.1							Fee Schedule																																															
NF-Liothyronine Sodium Oral Tablet 50MCG	250	RC						Both			4	1.8	1.8	3.6	2.6							Fee Schedule		2.96							Fee Schedule																													3.6							Fee Schedule																																															
NF-Liothyronine Sodium Oral Tablet 5MCG	250	RC						Both			2	0.9	0.9	1.8	1.3							Fee Schedule		1.48							Fee Schedule																													1.8							Fee Schedule																																															
NF-Lisinopril Tablet 2.5mg	250	RC						Both			1	0.45	0.45	0.9	0.65							Fee Schedule		0.74							Fee Schedule																													0.9							Fee Schedule																																															
NF-Lithium Carbonate Capsule 600MG	250	RC						Both			1	0.45	0.45	0.9	0.65							Fee Schedule		0.74							Fee Schedule																													0.9							Fee Schedule																																															
NF-Lithium Carbonate Tab ER 300MG	250	RC						Both			1	0.45	0.45	0.9	0.65							Fee Schedule		0.74							Fee Schedule																													0.9							Fee Schedule																																															
NF-Lokelma PwdforSusp 10GM/1Packet	250	RC						Both			103	46.35	46.35	92.7	66.95							Fee Schedule		76.22							Fee Schedule																													92.7							Fee Schedule																																															
NF-Lokelma PwdforSusp 5GM/1Packet	250	RC						Both			103	46.35	46.35	92.7	66.95							Fee Schedule		76.22							Fee Schedule																													92.7							Fee Schedule																																															
NF-Loperamide Oral Tablet 2MG	250	RC						Both			1	0.45	0.45	0.9	0.65							Fee Schedule		0.74							Fee Schedule																													0.9							Fee Schedule																																															
NF-Losartan/Hctz Oral Tablet 100MG-25MG	250	RC						Both			10	4.5	4.5	9	6.5							Fee Schedule		7.4							Fee Schedule																													9							Fee Schedule																																															
NF-Losartan/Hctz Oral Tablet 50MG-12.5MG	250	RC						Both			7	3.15	3.15	6.3	4.55							Fee Schedule		5.18							Fee Schedule																													6.3							Fee Schedule																																															
NF-Losartan/Hctz Oral Tablet 50MG-12.5MG	250	RC						Both			7	3.15	3.15	6.3	4.55							Fee Schedule		5.18							Fee Schedule																													6.3							Fee Schedule																																															
NF-Losartan/Hctz Oral Tablet 50MG-12.5MG	250	RC						Both			7	3.15	3.15	6.3	4.55							Fee Schedule		5.18							Fee Schedule																													6.3							Fee Schedule																																															
NF-Low-Ogestrel 28 Oral Tablet 30MCG-0.3	250	RC						Both			3	1.35	1.35	2.7	1.95							Fee Schedule		2.22							Fee Schedule																													2.7							Fee Schedule																																															
NF-Lunesta Tablet 1MG	250	RC						Both			129	58.05	58.05	116.1	83.85							Fee Schedule		95.46							Fee Schedule																													116.1							Fee Schedule																																															
NF-Lunesta Tablet 1MG	250	RC						Both			175	78.75	78.75	157.5	113.75							Fee Schedule		129.5							Fee Schedule																													157.5							Fee Schedule																																															
NF-Lunesta Tablet 1MG	250	RC						Both			175	78.75	78.75	157.5	113.75							Fee Schedule		129.5							Fee Schedule																													157.5							Fee Schedule																																															
NF-Lunesta Tablet 3MG	250	RC						Both			71	31.95	31.95	63.9	46.15							Fee Schedule		52.54							Fee Schedule																													63.9							Fee Schedule																																															
NF-Lunesta Tablet 3MG	250	RC						Both			71	31.95	31.95	63.9	46.15							Fee Schedule		52.54							Fee Schedule																													63.9							Fee Schedule																																															
NF-Lunesta Tablet 3MG	250	RC						Both			71	31.95	31.95	63.9	46.15							Fee Schedule		52.54							Fee Schedule																													63.9							Fee Schedule																																															
NF-Lunesta Tablet 3MG	250	RC						Both			71	31.95	31.95	63.9	46.15							Fee Schedule		52.54							Fee Schedule																													63.9							Fee Schedule																																															
NF-Lurasidone Hydrochloride Tablet 20MG	250	RC						Both			153	68.85	68.85	137.7	99.45							Fee Schedule		113.22							Fee Schedule																													137.7							Fee Schedule																																															
NF-Lurasidone Hydrochloride Tablet 40MG	250	RC						Both			153	68.85	68.85	137.7	99.45							Fee Schedule		113.22							Fee Schedule																													137.7							Fee Schedule																																															
NF-Lurasidone Hydrochloride Tablet 40MG	250	RC						Both			153	68.85	68.85	137.7	99.45							Fee Schedule		113.22							Fee Schedule																													137.7							Fee Schedule																																															
NF-Lurasidone Hydrochloride Tablet 40MG	250	RC						Both			151	67.95	67.95	135.9	98.15							Fee Schedule		111.74							Fee Schedule																													135.9							Fee Schedule																																															
NF-Lurasidone Hydrochloride Tablet 40MG	250	RC						Both			151	67.95	67.95	135.9	98.15							Fee Schedule		111.74							Fee Schedule																													135.9							Fee Schedule																																															
NF-Lyrica Oral Capsule 50MG	250	RC						Both			10	4.5	4.5	9	6.5							Fee Schedule		7.4							Fee Schedule																													9							Fee Schedule																																															
NF-MAGNESIUM CITRATE ORAL CAPSULE 100MG	250	RC						Both			0.84	0.38	0.38	0.76	0.55							Fee Schedule		0.62							Fee Schedule																													0.76							Fee Schedule																																															
NF-Melatonin Oral Capsule 20MG	250	RC						Both			1	0.45	0.45	0.9	0.65							Fee Schedule		0.74							Fee Schedule																													0.9							Fee Schedule																																															
NF-Memantine HCl Oral Capsule ER 14MG	250	RC						Both			45	20.25	20.25	40.5	29.25							Fee Schedule		33.3							Fee Schedule																													40.5							Fee Schedule																																															
NF-Memantine HCl Oral Capsule ER 28MG	250	RC						Both			45	20.25	20.25	40.5	29.25							Fee Schedule		33.3							Fee Schedule																													40.5							Fee Schedule																																															
NF-Memantine HCl Oral Tablet 5MG	250	RC						Both			18	8.1	8.1	16.2	11.7							Fee Schedule		13.32							Fee Schedule																													16.2							Fee Schedule																																															
NF-METFORMIN ER ORAL TAB ER 500MG	250	RC						Both			2.22	1	1	2	1.44							Fee Schedule		1.64							Fee Schedule																													2							Fee Schedule																																															
NF-metFORMIN HCl Oral Tab ER 750MG	250	RC						Both			3	1.35	1.35	2.7	1.95							Fee Schedule		2.22							Fee Schedule																													2.7							Fee Schedule																																															
"NF-metFORMIN HCl Oral Tab ER, 24HR 500MG"	250	RC						Both			3	1.35	1.35	2.7	1.95							Fee Schedule		2.22							Fee Schedule																													2.7							Fee Schedule																																															
NF-metFORMIN HCl Oral Tablet ER 1000MG	250	RC						Both			360	162	162	324	234							Fee Schedule		266.4							Fee Schedule																													324							Fee Schedule																																															
NF-metFORMIN HCl Oral Tablet ER 1000MG	250	RC						Both			360	162	162	324	234							Fee Schedule		266.4							Fee Schedule																													324							Fee Schedule																																															
NF-metFORMIN HCl Tab ER 24HR 500MG	250	RC						Both			51	22.95	22.95	45.9	33.15							Fee Schedule		37.74							Fee Schedule																													45.9							Fee Schedule																																															
NF-metFORMIN Hydrochloride Oral Tab 500M	250	RC						Both			2	0.9	0.9	1.8	1.3							Fee Schedule		1.48							Fee Schedule																													1.8							Fee Schedule																																															
NF-Methylphenidate HCl Oral Tab ER 63MG	250	RC						Both			72	32.4	32.4	64.8	46.8							Fee Schedule		53.28							Fee Schedule																													64.8							Fee Schedule																																															
NF-Methylphenidate Oral Tablet 20MG	250	RC						Both			4	1.8	1.8	3.6	2.6							Fee Schedule		2.96							Fee Schedule																													3.6							Fee Schedule																																															
NF-Methylphenidate Oral Tablet 5MG	250	RC						Both			1	0.45	0.45	0.9	0.65							Fee Schedule		0.74							Fee Schedule																													0.9							Fee Schedule																																															
NF-Mexiletine HCl Capsule 150MG	250	RC						Both			2	0.9	0.9	1.8	1.3							Fee Schedule		1.48							Fee Schedule																													1.8							Fee Schedule																																															
NF-Mirabegron Oral Tablet 50MG	250	RC						Both			49	22.05	22.05	44.1	31.85							Fee Schedule		36.26							Fee Schedule																													44.1							Fee Schedule																																															
NF-Monistat 3 Vaginal Cream 4%	250	RC						Both			4	1.8	1.8	3.6	2.6							Fee Schedule		2.96							Fee Schedule																													3.6							Fee Schedule																																															
NF-Monistat 7 Vaginal Cream 2%	250	RC						Both			1	0.45	0.45	0.9	0.65							Fee Schedule		0.74							Fee Schedule																													0.9							Fee Schedule																																															
NF-Morphine Sulfate Tablet 15MG	250	RC						Both			4	1.8	1.8	3.6	2.6							Fee Schedule		2.96							Fee Schedule																													3.6							Fee Schedule																																															
NF-Morphine Sulfate Tablet 30MG	250	RC						Both			4	1.8	1.8	3.6	2.6							Fee Schedule		2.96							Fee Schedule																													3.6							Fee Schedule																																															
NF-Mounjaro SubQ Soln 10MG/0.5ML	250	RC						Both			1943	874.35	874.35	1748.7	1262.95							Fee Schedule		1437.82							Fee Schedule																													1748.7							Fee Schedule																																															
NF-Mounjaro SubQ Soln 12.5MG/0.5ML	250	RC						Both			1943	874.35	874.35	1748.7	1262.95							Fee Schedule		1437.82							Fee Schedule																													1748.7							Fee Schedule																																															
NF-Mounjaro SubQ Soln 2.5MG/0.5ML	250	RC						Both			1943	874.35	874.35	1748.7	1262.95							Fee Schedule		1437.82							Fee Schedule																													1748.7							Fee Schedule																																															
NF-MOUNJARO SUBQ SOLN 5MG/0.5ML	250	RC						Both			1943.58	874.61	874.61	1749.22	1263.33							Fee Schedule		1438.25							Fee Schedule																													1749.22							Fee Schedule																																															
NF-Moxifloxacin HCl Ophth Soln 0.5%	250	RC						Both			167	75.15	75.15	150.3	108.55							Fee Schedule		123.58							Fee Schedule																													150.3							Fee Schedule																																															
NF-Mucinex DM Oral Tab ER 60MG-1200MG	250	RC						Both			2	0.9	0.9	1.8	1.3							Fee Schedule		1.48							Fee Schedule																													1.8							Fee Schedule																																															
NF-Mucinex DM Tab ER	250	RC						Both			1	0.45	0.45	0.9	0.65							Fee Schedule		0.74							Fee Schedule																													0.9							Fee Schedule																																															
NF-Mucinex Extended-Release Tablet 1200M	250	RC						Both			2	0.9	0.9	1.8	1.3							Fee Schedule		1.48							Fee Schedule																													1.8							Fee Schedule																																															
NF-Mucinex Extended-Release Tablet 1200M	250	RC						Both			2	0.9	0.9	1.8	1.3							Fee Schedule		1.48							Fee Schedule																													1.8							Fee Schedule																																															
NF-Mycophenolate Mofetil Oral Tablet 500	250	RC						Both			23	10.35	10.35	20.7	14.95							Fee Schedule		17.02							Fee Schedule																													20.7							Fee Schedule																																															
NF-Nebivolol Oral Tablet 10MG	250	RC						Both			14	6.3	6.3	12.6	9.1							Fee Schedule		10.36							Fee Schedule																													12.6							Fee Schedule																																															
NF-NovoLOG Inj Soln 100U/1ML	250	RC						Both			26	11.7	11.7	23.4	16.9							Fee Schedule		19.24							Fee Schedule																													23.4							Fee Schedule																																															
NF-Nuedexta Oral Capsule 20MG-10MG	250	RC						Both			100	45	45	90	65							Fee Schedule		74							Fee Schedule																													90							Fee Schedule																																															
NF-Nurtec ODT Oral Dis Tablet 75MG	250	RC						Both			463	208.35	208.35	416.7	300.95							Fee Schedule		342.62							Fee Schedule																													416.7							Fee Schedule																																															
NF-Ofev Oral Capsule 100MG	250	RC						Both			810	364.5	364.5	729	526.5							Fee Schedule		599.4							Fee Schedule																													729							Fee Schedule																																															
NF-OLANZapine Oral Tablet 5MG	250	RC						Both			39	17.55	17.55	35.1	25.35							Fee Schedule		28.86							Fee Schedule																													35.1							Fee Schedule																																															
NF-Olmesartan Medoxomil Oral Tablet 40MG	250	RC						Both			28	12.6	12.6	25.2	18.2							Fee Schedule		20.72							Fee Schedule																													25.2							Fee Schedule																																															
NF-Olopatadine HCl Ophthalmic Solution 0	250	RC						Both			160	72	72	144	104							Fee Schedule		118.4							Fee Schedule																													144							Fee Schedule																																															
NF-Ondansetron Disintegrating Tablet 8MG	250	RC						Both			109	49.05	49.05	98.1	70.85							Fee Schedule		80.66							Fee Schedule																													98.1							Fee Schedule																																															
NF-Onfi Oral Tablet 10MG	250	RC						Both			26	11.7	11.7	23.4	16.9							Fee Schedule		19.24							Fee Schedule																													23.4							Fee Schedule																																															
NF-Opcon-A Allergy Ophth Soln 0.027%-0.3	250	RC						Both			16	7.2	7.2	14.4	10.4							Fee Schedule		11.84							Fee Schedule																													14.4							Fee Schedule																																															
NF-Orencia Pre-Filled Syringe 125MG/1ML	250	RC						Both			5356	2410.2	2410.2	4820.4	3481.4							Fee Schedule		3963.44							Fee Schedule																													4820.4							Fee Schedule																																															
NF-Orencia Pre-Filled Syringe 125MG/1ML	250	RC						Both			5356	2410.2	2410.2	4820.4	3481.4							Fee Schedule		3963.44							Fee Schedule																													4820.4							Fee Schedule																																															
NF-Orphenadrine Citrate Tablet 100MG	250	RC						Both			6	2.7	2.7	5.4	3.9							Fee Schedule		4.44							Fee Schedule																													5.4							Fee Schedule																																															
NF-oxyCODONE Hydrochloride Oral Tablet 1	250	RC						Both			1	0.45	0.45	0.9	0.65							Fee Schedule		0.74							Fee Schedule																													0.9							Fee Schedule																																															
NF-oxyMORphone Hydrochloride Tab ER 15MG	250	RC						Both			46	20.7	20.7	41.4	29.9							Fee Schedule		34.04							Fee Schedule																													41.4							Fee Schedule																																															
NF-Paliperidone Oral Tablet ER 6MG	250	RC						Both			91	40.95	40.95	81.9	59.15							Fee Schedule		67.34							Fee Schedule																													81.9							Fee Schedule																																															
"NF-Paliperidone Oral Tablet, ER 6MG"	250	RC						Both			52	23.4	23.4	46.8	33.8							Fee Schedule		38.48							Fee Schedule																													46.8							Fee Schedule																																															
NF-Pantoprazole Sodium Oral Tab DR 40MG	250	RC						Both			12	5.4	5.4	10.8	7.8							Fee Schedule		8.88							Fee Schedule																													10.8							Fee Schedule																																															
NF-Pantoprazole Sodium Oral Tab DR 40MG	250	RC						Both			1	0.45	0.45	0.9	0.65							Fee Schedule		0.74							Fee Schedule																													0.9							Fee Schedule																																															
NF-Phenytoin Oral Chewable Tablet 50MG	250	RC						Both			1	0.45	0.45	0.9	0.65							Fee Schedule		0.74							Fee Schedule																													0.9							Fee Schedule																																															
NF-Phenytoin Oral Chewable Tablet 50MG	250	RC						Both			1	0.45	0.45	0.9	0.65							Fee Schedule		0.74							Fee Schedule																													0.9							Fee Schedule																																															
NF-Pirfenidone Oral Tablet 801MG	250	RC						Both			388	174.6	174.6	349.2	252.2							Fee Schedule		287.12							Fee Schedule																													349.2							Fee Schedule																																															
NF-Posaconazole Tablet DR 100MG	250	RC						Both			222	99.9	99.9	199.8	144.3							Fee Schedule		164.28							Fee Schedule																													199.8							Fee Schedule																																															
NF-Potassium Chloride Oral Tab ER 15mEq	250	RC						Both			2	0.9	0.9	1.8	1.3							Fee Schedule		1.48							Fee Schedule																													1.8							Fee Schedule																																															
NF-Potassium Chloride Tablet 10MEQ	250	RC						Both			1	0.45	0.45	0.9	0.65							Fee Schedule		0.74							Fee Schedule																													0.9							Fee Schedule																																															
NF-Potassium Chloride Tablet 10MEQ	250	RC						Both			1	0.45	0.45	0.9	0.65							Fee Schedule		0.74							Fee Schedule																													0.9							Fee Schedule																																															
NF-Potassium Chloride Tablet 10meq	250	RC						Both			1	0.45	0.45	0.9	0.65							Fee Schedule		0.74							Fee Schedule																													0.9							Fee Schedule																																															
"NF-potassium citrate Oral Tablet, ER 5ME"	250	RC						Both			5	2.25	2.25	4.5	3.25							Fee Schedule		3.7							Fee Schedule																													4.5							Fee Schedule																																															
NF-Pravastatin Sodium Oral Tablet 80MG	250	RC						Both			3	1.35	1.35	2.7	1.95							Fee Schedule		2.22							Fee Schedule																													2.7							Fee Schedule																																															
NF-Prazosin HCl Capsule 1MG	250	RC						Both			2	0.9	0.9	1.8	1.3							Fee Schedule		1.48							Fee Schedule																													1.8							Fee Schedule																																															
NF-Prazosin HCl Capsule 2MG	250	RC						Both			3	1.35	1.35	2.7	1.95							Fee Schedule		2.22							Fee Schedule																													2.7							Fee Schedule																																															
NF-Prazosin HCl Capsule 5MG	250	RC						Both			6	2.7	2.7	5.4	3.9							Fee Schedule		4.44							Fee Schedule																													5.4							Fee Schedule																																															
NF-Prazosin HCl Capsule 5MG	250	RC						Both			6	2.7	2.7	5.4	3.9							Fee Schedule		4.44							Fee Schedule																													5.4							Fee Schedule																																															
NF-Prazosin HCl Oral Capsule 2MG	250	RC						Both			3	1.35	1.35	2.7	1.95							Fee Schedule		2.22							Fee Schedule																													2.7							Fee Schedule																																															
NF-Prazosin Hydrochloride Oral Capsule 5	250	RC						Both			5	2.25	2.25	4.5	3.25							Fee Schedule		3.7							Fee Schedule																													4.5							Fee Schedule																																															
NF-PreserVision AREDS 2 + CoQ10 Liq Cap	250	RC						Both			1	0.45	0.45	0.9	0.65							Fee Schedule		0.74							Fee Schedule																													0.9							Fee Schedule																																															
NF-Prezcobix Oral Tablet 150MG-800MG	250	RC						Both			296	133.2	133.2	266.4	192.4							Fee Schedule		219.04							Fee Schedule																													266.4							Fee Schedule																																															
NF-Probenecid Tablet 500MG	250	RC						Both			3	1.35	1.35	2.7	1.95							Fee Schedule		2.22							Fee Schedule																													2.7							Fee Schedule																																															
NF-Procardia XL Tablet 60MG	250	RC						Both			41	18.45	18.45	36.9	26.65							Fee Schedule		30.34							Fee Schedule																													36.9							Fee Schedule																																															
NF-Procardia XL Tablet 60MG	250	RC						Both			41	18.45	18.45	36.9	26.65							Fee Schedule		30.34							Fee Schedule																													36.9							Fee Schedule																																															
NF-Procardia XL Tablet 60MG	250	RC						Both			41	18.45	18.45	36.9	26.65							Fee Schedule		30.34							Fee Schedule																													36.9							Fee Schedule																																															
NF-Prochlorperazine Maleate Tablet 10MG	250	RC						Both			2	0.9	0.9	1.8	1.3							Fee Schedule		1.48							Fee Schedule																													1.8							Fee Schedule																																															
NF-Prochlorperazine Maleate Tablet 10MG	250	RC						Both			2	0.9	0.9	1.8	1.3							Fee Schedule		1.48							Fee Schedule																													1.8							Fee Schedule																																															
NF-Progesterone Oral Capsule 100MG	250	RC						Both			6	2.7	2.7	5.4	3.9							Fee Schedule		4.44							Fee Schedule																													5.4							Fee Schedule																																															
NF-Propranolol ER Oral Cap ER 80MG	250	RC						Both			14	6.3	6.3	12.6	9.1							Fee Schedule		10.36							Fee Schedule																													12.6							Fee Schedule																																															
NF-Propranolol Hydrochloride Cap ER 60MG	250	RC						Both			6	2.7	2.7	5.4	3.9							Fee Schedule		4.44							Fee Schedule																													5.4							Fee Schedule																																															
NF-PROzac Capsule 20MG	250	RC						Both			62	27.9	27.9	55.8	40.3							Fee Schedule		45.88							Fee Schedule																													55.8							Fee Schedule																																															
NF-pyRIDostigmine Bromide Oral Tablet 30	250	RC						Both			26	11.7	11.7	23.4	16.9							Fee Schedule		19.24							Fee Schedule																													23.4							Fee Schedule																																															
NF-pyRIDostigmine Bromide Oral Tablet 60	250	RC						Both			3	1.35	1.35	2.7	1.95							Fee Schedule		2.22							Fee Schedule																													2.7							Fee Schedule																																															
NF-pyRIDostigmine Bromide Oral Tablet 60	250	RC						Both			7	3.15	3.15	6.3	4.55							Fee Schedule		5.18							Fee Schedule																													6.3							Fee Schedule																																															
NF-QUETIAPINE FUMARATE ORAL TAB ER 300MG	250	RC						Both			68.94	31.02	31.02	62.05	44.81							Fee Schedule		51.02							Fee Schedule																													62.05							Fee Schedule																																															
NF-QUEtiapine Fumarate Oral Tablet 300MG	250	RC						Both			50	22.5	22.5	45	32.5							Fee Schedule		37							Fee Schedule																													45							Fee Schedule																																															
NF-Rasagiline Oral Tablet 1MG	250	RC						Both			74	33.3	33.3	66.6	48.1							Fee Schedule		54.76							Fee Schedule																													66.6							Fee Schedule																																															
NF-Refresh Tears Ophth Solution 0.5%	250	RC						Both			2	0.9	0.9	1.8	1.3							Fee Schedule		1.48							Fee Schedule																													1.8							Fee Schedule																																															
NF-Renvela Oral Tablet 800MG	250	RC						Both			21	9.45	9.45	18.9	13.65							Fee Schedule		15.54							Fee Schedule																													18.9							Fee Schedule																																															
NF-Rexulti Oral Tablet 0.25MG	250	RC						Both			181	81.45	81.45	162.9	117.65							Fee Schedule		133.94							Fee Schedule																													162.9							Fee Schedule																																															
NF-Rexulti Oral Tablet 0.5MG	250	RC						Both			181	81.45	81.45	162.9	117.65							Fee Schedule		133.94							Fee Schedule																													162.9							Fee Schedule																																															
NF-Rexulti Oral Tablet 1MG	250	RC						Both			186	83.7	83.7	167.4	120.9							Fee Schedule		137.64							Fee Schedule																													167.4							Fee Schedule																																															
NF-Rexulti Oral Tablet 1MG	250	RC						Both			186	83.7	83.7	167.4	120.9							Fee Schedule		137.64							Fee Schedule																													167.4							Fee Schedule																																															
NF-RizatriptanBenzoate Disintegrat Tab 1	250	RC						Both			99	44.55	44.55	89.1	64.35							Fee Schedule		73.26							Fee Schedule																													89.1							Fee Schedule																																															
NF-Rocklatan Ophth Soln 0.02%-0.005%	250	RC						Both			509	229.05	229.05	458.1	330.85							Fee Schedule		376.66							Fee Schedule																													458.1							Fee Schedule																																															
NF-Rocklatan Ophth Soln 0.02%-0.005%	250	RC						Both			509	229.05	229.05	458.1	330.85							Fee Schedule		376.66							Fee Schedule																													458.1							Fee Schedule																																															
NF-rOPINIRole Hydrochloride Tablet 0.5MG	250	RC						Both			7	3.15	3.15	6.3	4.55							Fee Schedule		5.18							Fee Schedule																													6.3							Fee Schedule																																															
NF-Rosuvastatin Oral Tablet 40MG	250	RC						Both			26	11.7	11.7	23.4	16.9							Fee Schedule		19.24							Fee Schedule																													23.4							Fee Schedule																																															
NF-Rosuvastatin Oral Tablet 5MG	250	RC						Both			26	11.7	11.7	23.4	16.9							Fee Schedule		19.24							Fee Schedule																													23.4							Fee Schedule																																															
NF-Rybelsus Oral Tablet 14MG	250	RC						Both			119	53.55	53.55	107.1	77.35							Fee Schedule		88.06							Fee Schedule																													107.1							Fee Schedule																																															
NF-Rytary ExtendedRelease Cap 48.75MG-19	250	RC						Both			13	5.85	5.85	11.7	8.45							Fee Schedule		9.62							Fee Schedule																													11.7							Fee Schedule																																															
NF-Sacubitril and Valsartan Tab 49MG-51M	250	RC						Both			41	18.45	18.45	36.9	26.65							Fee Schedule		30.34							Fee Schedule																													36.9							Fee Schedule																																															
NF-Santyl Topical Ointment 250U/1GM	250	RC						Both			31	13.95	13.95	27.9	20.15							Fee Schedule		22.94							Fee Schedule																													27.9							Fee Schedule																																															
NF-Santyl Topical Ointment 250U/1GM	250	RC						Both			31	13.95	13.95	27.9	20.15							Fee Schedule		22.94							Fee Schedule																													27.9							Fee Schedule																																															
NF-Santyl Topical Ointment 250U/1GM	250	RC						Both			31	13.95	13.95	27.9	20.15							Fee Schedule		22.94							Fee Schedule																													27.9							Fee Schedule																																															
NF-Sertraline Oral Tablet 100MG	250	RC						Both			8	3.6	3.6	7.2	5.2							Fee Schedule		5.92							Fee Schedule																													7.2							Fee Schedule																																															
NF-Sertraline Oral Tablet 25MG	250	RC						Both			8	3.6	3.6	7.2	5.2							Fee Schedule		5.92							Fee Schedule																													7.2							Fee Schedule																																															
NF-Sodium Chloride Tablet 1GM	250	RC						Both			1	0.45	0.45	0.9	0.65							Fee Schedule		0.74							Fee Schedule																													0.9							Fee Schedule																																															
NF-Spiriva Respimat Inh Spray 2.5MCG/1Ac	250	RC						Both			474	213.3	213.3	426.6	308.1							Fee Schedule		350.76							Fee Schedule																													426.6							Fee Schedule																																															
NF-Spiriva Respimat Inst Pack 10ACT	250	RC						Both			67	30.15	30.15	60.3	43.55							Fee Schedule		49.58							Fee Schedule																													60.3							Fee Schedule																																															
NF-Spironolactone-HCTZ Tablet 25MG-25MG	250	RC						Both			3	1.35	1.35	2.7	1.95							Fee Schedule		2.22							Fee Schedule																													2.7							Fee Schedule																																															
NF-Suboxone Sublingual Film 8MG-2MG	250	RC						Both			32	14.4	14.4	28.8	20.8							Fee Schedule		23.68							Fee Schedule																													28.8							Fee Schedule																																															
NF-Suboxone Sublingual Film 8MG-2MG	250	RC						Both			32	14.4	14.4	28.8	20.8							Fee Schedule		23.68							Fee Schedule																													28.8							Fee Schedule																																															
NF-Symbicort Inh Aer Liq 160MCG-4.5MCG	250	RC						Both			82	36.9	36.9	73.8	53.3							Fee Schedule		60.68							Fee Schedule																													73.8							Fee Schedule																																															
NF-Symbicort Inh Aer Liq 160MCG-4.5MCG	250	RC						Both			82	36.9	36.9	73.8	53.3							Fee Schedule		60.68							Fee Schedule																													73.8							Fee Schedule																																															
NF-Symbicort Inh Aer Liq 160MCG-4.5MCG	250	RC						Both			82	36.9	36.9	73.8	53.3							Fee Schedule		60.68							Fee Schedule																													73.8							Fee Schedule																																															
NF-SYNTHROID ORAL TABLET 175MCG	250	RC						Both			2.75	1.24	1.24	2.48	1.79							Fee Schedule		2.04							Fee Schedule																													2.48							Fee Schedule																																															
NF-Tacrolimus Oral Capsule 1MG	250	RC						Both			13	5.85	5.85	11.7	8.45							Fee Schedule		9.62							Fee Schedule																													11.7							Fee Schedule																																															
NF-Tadalafil Oral Tablet 10MG	250	RC						Both			228	102.6	102.6	205.2	148.2							Fee Schedule		168.72							Fee Schedule																													205.2							Fee Schedule																																															
NF-Tadalafil Oral Tablet 5MG	250	RC						Both			38	17.1	17.1	34.2	24.7							Fee Schedule		28.12							Fee Schedule																													34.2							Fee Schedule																																															
NF-Teglutik Oral Suspension 5MG/1ML	250	RC						Both			23	10.35	10.35	20.7	14.95							Fee Schedule		17.02							Fee Schedule																													20.7							Fee Schedule																																															
NF-TEGLUTIK ORAL SUSPENSION 5MG/1ML	250	RC						Both			132.94	59.82	59.82	119.65	86.41							Fee Schedule		98.38							Fee Schedule																													119.65							Fee Schedule																																															
NF-TEGLUTIK ORAL SUSPENSION 5MG/1ML	250	RC						Both			132.96	59.83	59.83	119.66	86.42							Fee Schedule		98.39							Fee Schedule																													119.66							Fee Schedule																																															
NF-terbinafine Oral Tablet 250MG	250	RC						Both			1	0.45	0.45	0.9	0.65							Fee Schedule		0.74							Fee Schedule																													0.9							Fee Schedule																																															
NF-terbinafine Oral Tablet 250MG	250	RC						Both			38	17.1	17.1	34.2	24.7							Fee Schedule		28.12							Fee Schedule																													34.2							Fee Schedule																																															
NF-Terconazole Vaginal Cream 0.8%	250	RC						Both			6	2.7	2.7	5.4	3.9							Fee Schedule		4.44							Fee Schedule																													5.4							Fee Schedule																																															
NF-Terconazole Vaginal Cream 0.8%	250	RC						Both			6	2.7	2.7	5.4	3.9							Fee Schedule		4.44							Fee Schedule																													5.4							Fee Schedule																																															
NF-tiaGABine Hydrochloride Oral Tablet 4	250	RC						Both			23	10.35	10.35	20.7	14.95							Fee Schedule		17.02							Fee Schedule																													20.7							Fee Schedule																																															
NF-Timolol Ophthalmic Solution 0.5%	250	RC						Both			105	47.25	47.25	94.5	68.25							Fee Schedule		77.7							Fee Schedule																													94.5							Fee Schedule																																															
NF-Tiotropium Bromide Inh Cap 18MCG	250	RC						Both			55	24.75	24.75	49.5	35.75							Fee Schedule		40.7							Fee Schedule																													49.5							Fee Schedule																																															
NF-Tivicay Oral Tablet 50MG	250	RC						Both			270	121.5	121.5	243	175.5							Fee Schedule		199.8							Fee Schedule																													243							Fee Schedule																																															
NF-Toujeo Max SubQ Solution 300U/1ML	250	RC						Both			342	153.9	153.9	307.8	222.3							Fee Schedule		253.08							Fee Schedule																													307.8							Fee Schedule																																															
NF-traMADol HCl/APAP Tab 37.5MG-325MG	250	RC						Both			3	1.35	1.35	2.7	1.95							Fee Schedule		2.22							Fee Schedule																													2.7							Fee Schedule																																															
NF-Travoprost Ophthalmic Solution 0.004%	250	RC						Both			238	107.1	107.1	214.2	154.7							Fee Schedule		176.12							Fee Schedule																													214.2							Fee Schedule																																															
NF-TraZODone HCl Oral Tablet 100MG	250	RC						Both			4	1.8	1.8	3.6	2.6							Fee Schedule		2.96							Fee Schedule																													3.6							Fee Schedule																																															
NF-TraZODone Hydrochloride Oral Tablet 5	250	RC						Both			3	1.35	1.35	2.7	1.95							Fee Schedule		2.22							Fee Schedule																													2.7							Fee Schedule																																															
NF-Trelegy Ellipta 100/62.5/25MCG/INH	250	RC						Both			39	17.55	17.55	35.1	25.35							Fee Schedule		28.86							Fee Schedule																													35.1							Fee Schedule																																															
NF-Trelegy Ellipta 100/62.5/25MCG/INH	250	RC						Both			39	17.55	17.55	35.1	25.35							Fee Schedule		28.86							Fee Schedule																													35.1							Fee Schedule																																															
NF-Trelegy Ellipta 100/62.5/25MCG/INH	250	RC						Both			39	17.55	17.55	35.1	25.35							Fee Schedule		28.86							Fee Schedule																													35.1							Fee Schedule																																															
NF-Trelegy Ellipta 100/62.5/25MCG/INH	250	RC						Both			39	17.55	17.55	35.1	25.35							Fee Schedule		28.86							Fee Schedule																													35.1							Fee Schedule																																															
NF-Trelegy Ellipta 100/62.5/25MCG/INH	250	RC						Both			40	18	18	36	26							Fee Schedule		29.6							Fee Schedule																													36							Fee Schedule																																															
NF-Trelegy Ellipta 100/62.5/25MCG/INH	250	RC						Both			40	18	18	36	26							Fee Schedule		29.6							Fee Schedule																													36							Fee Schedule																																															
NF-Trelegy Ellipta 100/62.5/25MCG/INH	250	RC						Both			40	18	18	36	26							Fee Schedule		29.6							Fee Schedule																													36							Fee Schedule																																															
NF-Trelegy Ellipta 100/62.5/25MCG/INH	250	RC						Both			40	18	18	36	26							Fee Schedule		29.6							Fee Schedule																													36							Fee Schedule																																															
NF-Trelegy Ellipta 100/62.5/25MCG/INH	250	RC						Both			40	18	18	36	26							Fee Schedule		29.6							Fee Schedule																													36							Fee Schedule																																															
NF-Trelegy Ellipta 100/62.5/25MCG/INH	250	RC						Both			40	18	18	36	26							Fee Schedule		29.6							Fee Schedule																													36							Fee Schedule																																															
NF-Trelegy Ellipta 100/62.5/25MCG/INH	250	RC						Both			40	18	18	36	26							Fee Schedule		29.6							Fee Schedule																													36							Fee Schedule																																															
NF-Trelegy Ellipta 100/62.5/25MCG/INH	250	RC						Both			40	18	18	36	26							Fee Schedule		29.6							Fee Schedule																													36							Fee Schedule																																															
NF-Trelegy Ellipta 100/62.5/25MCG/INH	250	RC						Both			40	18	18	36	26							Fee Schedule		29.6							Fee Schedule																													36							Fee Schedule																																															
NF-Trelegy Ellipta 100/62.5/25MCG/INH	250	RC						Both			40	18	18	36	26							Fee Schedule		29.6							Fee Schedule																													36							Fee Schedule																																															
NF-Trelegy Ellipta 100/62.5/25MCG/INH	250	RC						Both			41	18.45	18.45	36.9	26.65							Fee Schedule		30.34							Fee Schedule																													36.9							Fee Schedule																																															
NF-Trelegy Ellipta 200/62.5/25MCG/INH	250	RC						Both			40	18	18	36	26							Fee Schedule		29.6							Fee Schedule																													36							Fee Schedule																																															
NF-Trelegy Ellipta 200/62.5/25MCG/INH	250	RC						Both			40	18	18	36	26							Fee Schedule		29.6							Fee Schedule																													36							Fee Schedule																																															
NF-Trelegy Ellipta 200/62.5/25MCG/INH	250	RC						Both			40	18	18	36	26							Fee Schedule		29.6							Fee Schedule																													36							Fee Schedule																																															
NF-Trelegy Ellipta 200/62.5/25MCG/INH	250	RC						Both			40	18	18	36	26							Fee Schedule		29.6							Fee Schedule																													36							Fee Schedule																																															
NF-Trelegy Ellipta 200/62.5/25MCG/INH	250	RC						Both			40	18	18	36	26							Fee Schedule		29.6							Fee Schedule																													36							Fee Schedule																																															
NF-Tretinoin Topical Cream 0.025%	250	RC						Both			19	8.55	8.55	17.1	12.35							Fee Schedule		14.06							Fee Schedule																													17.1							Fee Schedule																																															
NF-Triamcinolone Acetonide Cream 0.5%	250	RC						Both			2	0.9	0.9	1.8	1.3							Fee Schedule		1.48							Fee Schedule																													1.8							Fee Schedule																																															
NF-Triamcinolone Acetonide Spray 55MCG/1	250	RC						Both			2	0.9	0.9	1.8	1.3							Fee Schedule		1.48							Fee Schedule																													1.8							Fee Schedule																																															
NF-Triamterene/HCTZ Capsule 37.5-25MG	250	RC						Both			1	0.45	0.45	0.9	0.65							Fee Schedule		0.74							Fee Schedule																													0.9							Fee Schedule																																															
NF-Tribenzor Oral Tablet 20-5-12.5MG	250	RC						Both			52	23.4	23.4	46.8	33.8							Fee Schedule		38.48							Fee Schedule																													46.8							Fee Schedule																																															
NF-Trifluoperazine HCl Tablet 2MG	250	RC						Both			3	1.35	1.35	2.7	1.95							Fee Schedule		2.22							Fee Schedule																													2.7							Fee Schedule																																															
NF-Trimethoprim Tablet 100MG	250	RC						Both			6	2.7	2.7	5.4	3.9							Fee Schedule		4.44							Fee Schedule																													5.4							Fee Schedule																																															
NF-Trintellix Oral Tablet 20MG	250	RC						Both			38	17.1	17.1	34.2	24.7							Fee Schedule		28.12							Fee Schedule																													34.2							Fee Schedule																																															
"NF-TriphroCaps Oral Capsule, Liquid Fill"	250	RC						Both			2	0.9	0.9	1.8	1.3							Fee Schedule		1.48							Fee Schedule																													1.8							Fee Schedule																																															
NF-Trospium Chloride Oral Capsule ER 60M	250	RC						Both			20	9	9	18	13							Fee Schedule		14.8							Fee Schedule																													18							Fee Schedule																																															
NF-Trospium Chloride Oral Tablet 20MG	250	RC						Both			8	3.6	3.6	7.2	5.2							Fee Schedule		5.92							Fee Schedule																													7.2							Fee Schedule																																															
NF-Trospium Chloride Oral Tablet 20MG	250	RC						Both			8	3.6	3.6	7.2	5.2							Fee Schedule		5.92							Fee Schedule																													7.2							Fee Schedule																																															
NF-Trospium Chloride Oral Tablet 20MG	250	RC						Both			8	3.6	3.6	7.2	5.2							Fee Schedule		5.92							Fee Schedule																													7.2							Fee Schedule																																															
NF-Trospium Chloride Oral Tablet 20MG	250	RC						Both			2	0.9	0.9	1.8	1.3							Fee Schedule		1.48							Fee Schedule																													1.8							Fee Schedule																																															
NF-Trudhesa Nasal Spray 4MG/1ML	250	RC						Both			4562	2052.9	2052.9	4105.8	2965.3							Fee Schedule		3375.88							Fee Schedule																													4105.8							Fee Schedule																																															
NF-Trulicity SubQ Solution 0.75MG/0.5ML	250	RC						Both			1776	799.2	799.2	1598.4	1154.4							Fee Schedule		1314.24							Fee Schedule																													1598.4							Fee Schedule																																															
NF-Trulicity SubQ Solution 0.75MG/0.5ML	250	RC						Both			1595	717.75	717.75	1435.5	1036.75							Fee Schedule		1180.3							Fee Schedule																													1435.5							Fee Schedule																																															
NF-Tyenne Autoinjector SubQ 162MG/0.9ML	250	RC						Both			3054	1374.3	1374.3	2748.6	1985.1							Fee Schedule		2259.96							Fee Schedule																													2748.6							Fee Schedule																																															
NF-valACYclovir Hydrochloride Oral Tab 1	250	RC						Both			37	16.65	16.65	33.3	24.05							Fee Schedule		27.38							Fee Schedule																													33.3							Fee Schedule																																															
NF-Varenicline Oral Tab 1MG	250	RC						Both			19	8.55	8.55	17.1	12.35							Fee Schedule		14.06							Fee Schedule																													17.1							Fee Schedule																																															
NF-Varenicline Oral Tab 1MG	250	RC						Both			27	12.15	12.15	24.3	17.55							Fee Schedule		19.98							Fee Schedule																													24.3							Fee Schedule																																															
NF-Venlafaxine HCl Oral Cap ER 150MG	250	RC						Both			15	6.75	6.75	13.5	9.75							Fee Schedule		11.1							Fee Schedule																													13.5							Fee Schedule																																															
NF-Venlafaxine HCl Oral Cap ER 150MG	250	RC						Both			15	6.75	6.75	13.5	9.75							Fee Schedule		11.1							Fee Schedule																													13.5							Fee Schedule																																															
NF-Venlafaxine Hydrochloride Tablet 100M	250	RC						Both			6	2.7	2.7	5.4	3.9							Fee Schedule		4.44							Fee Schedule																													5.4							Fee Schedule																																															
NF-Venlafaxine Hydrochloride Tablet 100M	250	RC						Both			6	2.7	2.7	5.4	3.9							Fee Schedule		4.44							Fee Schedule																													5.4							Fee Schedule																																															
NF-Venlafaxine Hydrochloride Tablet 50MG	250	RC						Both			6	2.7	2.7	5.4	3.9							Fee Schedule		4.44							Fee Schedule																													5.4							Fee Schedule																																															
NF-Verquvo Oral Tablet 5MG	250	RC						Both			83	37.35	37.35	74.7	53.95							Fee Schedule		61.42							Fee Schedule																													74.7							Fee Schedule																																															
NF-Verzenio Tab 100MG	250	RC						Both			1049	472.05	472.05	944.1	681.85							Fee Schedule		776.26							Fee Schedule																													944.1							Fee Schedule																																															
NF-Verzenio Tab 50MG	250	RC						Both			1049	472.05	472.05	944.1	681.85							Fee Schedule		776.26							Fee Schedule																													944.1							Fee Schedule																																															
NF-Verzenio Tab 50MG	250	RC						Both			1049	472.05	472.05	944.1	681.85							Fee Schedule		776.26							Fee Schedule																													944.1							Fee Schedule																																															
NF-Vimpat Oral Tablet 150MG	250	RC						Both			73	32.85	32.85	65.7	47.45							Fee Schedule		54.02							Fee Schedule																													65.7							Fee Schedule																																															
NF-Vitamin D3 Oral Cap 1250MCG	250	RC						Both			3	1.35	1.35	2.7	1.95							Fee Schedule		2.22							Fee Schedule																													2.7							Fee Schedule																																															
NF-Vivelle-Dot TD Patch ER 0.1MG/24hr	250	RC						Both			69	31.05	31.05	62.1	44.85							Fee Schedule		51.06							Fee Schedule																													62.1							Fee Schedule																																															
NF-Voquezna Oral Tablet 20MG	250	RC						Both			81	36.45	36.45	72.9	52.65							Fee Schedule		59.94							Fee Schedule																													72.9							Fee Schedule																																															
NF-Voquezna Oral Tablet 20MG	250	RC						Both			81	36.45	36.45	72.9	52.65							Fee Schedule		59.94							Fee Schedule																													72.9							Fee Schedule																																															
NF-Vraylar Oral Capsule 1.5MG	250	RC						Both			182	81.9	81.9	163.8	118.3							Fee Schedule		134.68							Fee Schedule																													163.8							Fee Schedule																																															
NF-Vraylar Oral Capsule 1.5MG	250	RC						Both			182	81.9	81.9	163.8	118.3							Fee Schedule		134.68							Fee Schedule																													163.8							Fee Schedule																																															
NF-VRAYLAR ORAL CAPSULE 1.5MG	250	RC						Both			182.27	82.02	82.02	164.04	118.48							Fee Schedule		134.88							Fee Schedule																													164.04							Fee Schedule																																															
NF-Vraylar Oral Capsule 1.5MG	250	RC						Both			182	81.9	81.9	163.8	118.3							Fee Schedule		134.68							Fee Schedule																													163.8							Fee Schedule																																															
NF-Vraylar Oral Capsule 1.5MG	250	RC						Both			182	81.9	81.9	163.8	118.3							Fee Schedule		134.68							Fee Schedule																													163.8							Fee Schedule																																															
NF-Vraylar Oral Capsule 1.5MG	250	RC						Both			182	81.9	81.9	163.8	118.3							Fee Schedule		134.68							Fee Schedule																													163.8							Fee Schedule																																															
NF-Vraylar Oral Capsule 1.5MG	250	RC						Both			182	81.9	81.9	163.8	118.3							Fee Schedule		134.68							Fee Schedule																													163.8							Fee Schedule																																															
NF-Vraylar Oral Capsule 3MG	250	RC						Both			173	77.85	77.85	155.7	112.45							Fee Schedule		128.02							Fee Schedule																													155.7							Fee Schedule																																															
NF-Vraylar Oral Capsule 3MG	250	RC						Both			182	81.9	81.9	163.8	118.3							Fee Schedule		134.68							Fee Schedule																													163.8							Fee Schedule																																															
NF-Vyzulta Ophthalmic Solution 0.024%	250	RC						Both			373	167.85	167.85	335.7	242.45							Fee Schedule		276.02							Fee Schedule																													335.7							Fee Schedule																																															
NF-Welchol Pwd for Susp 3.75GM/1 Packet	250	RC						Both			117	52.65	52.65	105.3	76.05							Fee Schedule		86.58							Fee Schedule																													105.3							Fee Schedule																																															
NF-Wixela Inhub Inhalation Disk 500/50	250	RC						Both			29	13.05	13.05	26.1	18.85							Fee Schedule		21.46							Fee Schedule																													26.1							Fee Schedule																																															
NF-Xcopri Oral Tab 100MG	250	RC						Both			145	65.25	65.25	130.5	94.25							Fee Schedule		107.3							Fee Schedule																													130.5							Fee Schedule																																															
NF-Xeljanz Oral Tablet 5MG	250	RC						Both			364	163.8	163.8	327.6	236.6							Fee Schedule		269.36							Fee Schedule																													327.6							Fee Schedule																																															
NF-Xiidra Ophthalmic Solution 5%	250	RC						Both			33	14.85	14.85	29.7	21.45							Fee Schedule		24.42							Fee Schedule																													29.7							Fee Schedule																																															
NF-Xiidra Ophthalmic Solution 5%	250	RC						Both			33	14.85	14.85	29.7	21.45							Fee Schedule		24.42							Fee Schedule																													29.7							Fee Schedule																																															
NF-Xyzal Allergy 24HR Oral Tablet 5MG	250	RC						Both			3	1.35	1.35	2.7	1.95							Fee Schedule		2.22							Fee Schedule																													2.7							Fee Schedule																																															
NF-Yupelri Inhalation Solution 175MCG/3M	250	RC						Both			63	28.35	28.35	56.7	40.95							Fee Schedule		46.62							Fee Schedule																													56.7							Fee Schedule																																															
NF-Zepbound SubQ Soln 5MG/0.5ML	250	RC						Both			898	404.1	404.1	808.2	583.7							Fee Schedule		664.52							Fee Schedule																													808.2							Fee Schedule																																															
NF-ZyPREXA Tablet 10MG	250	RC						Both			85	38.25	38.25	76.5	55.25							Fee Schedule		62.9							Fee Schedule																													76.5							Fee Schedule																																															
NG STRIP #NG50	250	RC						Both			2	0.9	0.9	1.8	1.3							Fee Schedule		1.48							Fee Schedule																													1.8							Fee Schedule																																															
NG TUBE 12 FR.	272	RC	B4083	CPT				Both			121.8	54.81	0.91	109.62	0.91							Fee Schedule		90.13							Fee Schedule											3.05							Fee Schedule											109.62							Fee Schedule																																															
NIACIN  50 MG TABLET UD	250	RC	A9270	CPT				Both			1.58	0.71	0.01	1.42	0.01							Fee Schedule		1.17							Fee Schedule																													1.42							Fee Schedule																																															
NIACIN 100 MG TABLET UD	250	RC	A9270	CPT				Both			4.2	1.89	0.01	3.78	0.01							Fee Schedule		3.11							Fee Schedule																													3.78							Fee Schedule																																															
NIACIN 500 MG TABLET	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
NIACIN SR 250 MG CAPSULE	250	RC	A9270	CPT				Both			1.58	0.71	0.01	1.42	0.01							Fee Schedule		1.17							Fee Schedule																													1.42							Fee Schedule																																															
NIASPAN ER 500 MG TABLET	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
NICARDIPINE 20MG/200ML (CARDENE)PREMIX	250	RC	J2404	CPT				Both			384.3	172.94	0.07	345.87	249.8							Fee Schedule		284.38							Fee Schedule		0.07							Fee Schedule																				345.87							Fee Schedule																																															
NICARDIPINE 25MG/10ML VIAL	250	RC	J2404	CPT				Both			76.65	34.49	0.07	68.99	49.82							Fee Schedule		56.72							Fee Schedule		0.07							Fee Schedule											0.07							Fee Schedule		68.99							Fee Schedule		0.08							Fee Schedule		0.07							Fee Schedule											0.08							Fee Schedule		0.07							Fee Schedule		
NICKEL 4696 TMF ROYAL BLUE	301	RC	83885	CPT				Both			290.85	130.88	0.07	261.77	21.79							Fee Schedule		27.23							Fee Schedule		25.25							Fee Schedule		24.51							Fee Schedule		0.07							Fee Schedule		261.77							Fee Schedule		0.08							Fee Schedule		0.07							Fee Schedule		24.51							Fee Schedule		0.08							Fee Schedule		0.07							Fee Schedule		
NICKEL 5215 UR 24HR	301	RC	83885	CPT				Both			290.85	130.88	21.79	261.77	21.79							Fee Schedule		27.23							Fee Schedule		25.25							Fee Schedule		24.51							Fee Schedule		24.51							Fee Schedule		261.77							Fee Schedule		28.19							Fee Schedule		22.79							Fee Schedule		24.51							Fee Schedule		28.19							Fee Schedule		22.79							Fee Schedule		
NICOBID 250 MG CAPSULE	250	RC	A9270	CPT				Both			1.58	0.71	0.01	28.19	0.01							Fee Schedule		1.17							Fee Schedule																				24.51							Fee Schedule		1.42							Fee Schedule		28.19							Fee Schedule		22.79							Fee Schedule											28.19							Fee Schedule		22.79							Fee Schedule		
NICOTINE  7 MG TRANSDERMAL PATCH	250	RC	S4991	CPT				Both			7.35	3.31	2.08	6.62	2.08							Fee Schedule		5.44							Fee Schedule																													6.62							Fee Schedule																																															
NICOTINE & COTININE  90642	300	RC	80323	CPT				Both			160.92	72.41	0.01	144.83	0.01							Fee Schedule									Other	No Additional Reimbursement 																												144.83							Fee Schedule																																															
NICOTINE 14 MG TRANSDERMAL PATCH	250	RC	S4991	CPT				Both			7.35	3.31	2.08	6.62	2.08							Fee Schedule		5.44							Fee Schedule																													6.62							Fee Schedule																																															
NICOTINE 21 MG TRANSDERMAL PATCH	250	RC	S4991	CPT				Both			7.35	3.31	2.08	6.62	2.08							Fee Schedule		5.44							Fee Schedule																													6.62							Fee Schedule																																															
NICOTINE METABOLITE SCREEN UR  90646	301	RC	80323	CPT				Both			150	67.5	0.01	135	0.01							Fee Schedule									Other	No Additional Reimbursement 																												135							Fee Schedule																																															
NICOTROL INHALER	250	RC	A9270	CPT				Both			117.6	52.92	0.01	105.84	0.01							Fee Schedule		87.02							Fee Schedule																													105.84							Fee Schedule																																															
NIFEDIPINE 10MG (PROCARDIA) CAPSULE	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
NIFEDIPINE 10MG PRO	250	RC	A9270	CPT				Both			2.1	0.95	0.01	1.89	0.01							Fee Schedule		1.55							Fee Schedule																													1.89							Fee Schedule																																															
NIFEDIPINE ER 30MG (PROCARDIA XL) TABLET	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
NIFEDIPINE ER 60 MG CAPSULE UD	250	RC	A9270	CPT				Both			6.66	3	0.01	5.99	0.01							Fee Schedule		4.93							Fee Schedule																													5.99							Fee Schedule																																															
NIFEDIPINE ER 90 MG CAPSULE UD	250	RC	A9270	CPT				Both			8.72	3.92	0.01	7.85	0.01							Fee Schedule		6.45							Fee Schedule																													7.85							Fee Schedule																																															
NIFEREX 150 MG TABS	250	RC	A9270	CPT				Both			1.58	0.71	0.01	1.42	0.01							Fee Schedule		1.17							Fee Schedule																													1.42							Fee Schedule																																															
NIH.KOHD. CO2 ADAPTOR INTUBATED #YG-111T	270	RC						Both			31	13.95	13.95	27.9	20.15							Fee Schedule		22.94							Fee Schedule																													27.9							Fee Schedule																																															
NIH.KOHD. CO2 ADAPTOR NONINTUB. #YG-122T	270	RC						Both			29	13.05	13.05	26.1	18.85							Fee Schedule		21.46							Fee Schedule																													26.1							Fee Schedule																																															
NIHON KOH. AIRWAY ADAPTOR YG-101T*DISC*	270	RC						Both			33.6	15.12	15.12	30.24	21.84							Fee Schedule		24.86							Fee Schedule																													30.24							Fee Schedule																																															
NIHON KOHDEN CO2 ADAPTOR ER YG-111T	270	RC						Both			31	13.95	13.95	27.9	20.15							Fee Schedule		22.94							Fee Schedule																													27.9							Fee Schedule																																															
NIMODIPINE 30 MG CAPSULE UD	250	RC	A9270	CPT				Both			18.05	8.12	0.01	16.25	0.01							Fee Schedule		13.36							Fee Schedule																													16.25							Fee Schedule																																															
NIPPLES	271	RC						Both			6.3	2.84	2.84	5.67	4.1							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
NIPPLES 12 PK.	271	RC						Both			47.25	21.26	21.26	42.53	30.71							Fee Schedule		34.97							Fee Schedule																													42.53							Fee Schedule																																															
NIPPLES 8 PK.	271	RC						Both			13.65	6.14	6.14	12.29	8.87							Fee Schedule		10.1							Fee Schedule																													12.29							Fee Schedule																																															
NITAZOXANIDE 500 MG TABLET UD	250	RC	A9270	CPT				Both			47.25	21.26	0.01	42.53	0.01							Fee Schedule		34.97							Fee Schedule																													42.53							Fee Schedule																																															
NitraTEST PAPER	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
NITROBID 2% TOPICAL OINT PCKTS	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
NITROFURANTOIN 50MG (MACRODANTIN) CAP	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
NITROFURANTOIN MONO/MACROCRYSTALS 100MG	250	RC	A9270	CPT				Both			9.45	4.25	0.01	8.51	0.01							Fee Schedule		6.99							Fee Schedule																													8.51							Fee Schedule																																															
NITROGLYCERIN 0.1 MG/HR TRANDERMAL PATCH	250	RC	A9270	CPT				Both			8.4	3.78	0.01	7.56	0.01							Fee Schedule		6.22							Fee Schedule																													7.56							Fee Schedule																																															
NITROGLYCERIN 0.2 MG/HR TRANDERMAL PATCH	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
NITROGLYCERIN 0.2 MG/HR TRANSDERM PATCH	250	RC	A9270	CPT				Both			5.25	2.36	0.01	4.73	0.01							Fee Schedule		3.89							Fee Schedule																													4.73							Fee Schedule																																															
NITROGLYCERIN 0.3 MG/HR TRANSDERMAL PATC	250	RC	A9270	CPT				Both			59.85	26.93	0.01	53.87	0.01							Fee Schedule		44.29							Fee Schedule																													53.87							Fee Schedule																																															
NITROGLYCERIN 0.4 MG/HR TRANSDERMAL PATC	250	RC	A9270	CPT				Both			9.45	4.25	0.01	8.51	0.01							Fee Schedule		6.99							Fee Schedule																													8.51							Fee Schedule																																															
NITROGLYCERIN 0.6 MG/HR TRANSDERMAL PATC	250	RC	A9270	CPT				Both			9.45	4.25	0.01	8.51	0.01							Fee Schedule		6.99							Fee Schedule																													8.51							Fee Schedule																																															
NITROGLYCERIN 0.8 MG/HR TRANSDERMAL PATC	250	RC	A9270	CPT				Both			12.68	5.71	0.01	11.41	0.01							Fee Schedule		9.38							Fee Schedule																													11.41							Fee Schedule																																															
NITROGLYCERIN 2% OINTMENT- 120GM TUBE	250	RC	A9270	CPT				Both			25.14	11.31	0.01	22.63	0.01							Fee Schedule		18.6							Fee Schedule																													22.63							Fee Schedule																																															
NITROGLYCERIN 2.5MG ER CAPSULE UD	250	RC	A9270	CPT				Both			4.2	1.89	0.01	3.78	0.01							Fee Schedule		3.11							Fee Schedule																													3.78							Fee Schedule																																															
NITROGLYCERIN 25 MG/250 ML PREMIX( IVPB)	250	RC	J2305	CPT				Both			59.85	26.93	1.6	53.87	38.9							Fee Schedule		44.29							Fee Schedule		1.6							Fee Schedule																				53.87							Fee Schedule																																															
NITROGLYCERIN 6.5 MG ER CAPSULE UD	250	RC	A9270	CPT				Both			5.25	2.36	0.01	4.73	0.01							Fee Schedule		3.89							Fee Schedule																				1.56							Fee Schedule		4.73							Fee Schedule		1.79							Fee Schedule		1.45							Fee Schedule											1.79							Fee Schedule		1.45							Fee Schedule		
NITROGLYCERIN 9 MG ER CAPSULE UD	250	RC	A9270	CPT				Both			1.58	0.71	0.01	1.42	0.01							Fee Schedule		1.17							Fee Schedule																													1.42							Fee Schedule																																															
NITROGLYCERIN PREMIX 1A0692	258	RC						Both			31.5	14.18	14.18	28.35	20.48							Fee Schedule		23.31							Fee Schedule																													28.35							Fee Schedule																																															
NITROGLYCERIN SET #2C7551	272	RC						Both			22	9.9	9.9	19.8	14.3							Fee Schedule		16.28							Fee Schedule																													19.8							Fee Schedule																																															
NITROL OINT (TUBE)	250	RC	A9270	CPT				Both			28.35	12.76	0.01	25.52	0.01							Fee Schedule		20.98							Fee Schedule																													25.52							Fee Schedule																																															
NITROLINGUAL PUMPSPRAY 400MCG/SPRAY	250	RC	A9270	CPT				Both			622.98	280.34	0.01	560.68	0.01							Fee Schedule		461.01							Fee Schedule																													560.68							Fee Schedule																																															
NITROPRESS 50MG/2ML VIAL	250	RC	93463	CPT				Both			1134	510.3	84.08	1020.6	94.59							Fee Schedule		839.16							Fee Schedule											84.08							Fee Schedule											1020.6							Fee Schedule																																															
NITROPRESS 50MG/D5W 250ML DRIP	250	RC	A9270	CPT				Both			1141.35	513.61	0.01	1027.22	0.01							Fee Schedule		844.6							Fee Schedule																													1027.22							Fee Schedule																																															
NITROSTAT 0.3 MG SUBLING TABLET	250	RC	A9270	CPT				Both			80.51	36.23	0.01	72.46	0.01							Fee Schedule		59.58							Fee Schedule																													72.46							Fee Schedule																																															
NITROSTAT 0.3 MG TABLET UD	250	RC	A9270	CPT				Both			19.03	8.56	0.01	17.13	0.01							Fee Schedule		14.08							Fee Schedule																													17.13							Fee Schedule																																															
NITROSTAT 0.4 MG SUBLING TABLET	250	RC	A9270	CPT				Both			123.9	55.76	0.01	111.51	0.01							Fee Schedule		91.69							Fee Schedule																													111.51							Fee Schedule																																															
NITROSTAT 0.6 MG TABLET UD	250	RC	A9270	CPT				Both			5.25	2.36	0.01	4.73	0.01							Fee Schedule		3.89							Fee Schedule																													4.73							Fee Schedule																																															
NIZORAL SHAMPOO 120ML (KETOCONAZOLE)	250	RC	A9270	CPT				Both			65.1	29.3	0.01	58.59	0.01							Fee Schedule		48.17							Fee Schedule																													58.59							Fee Schedule																																															
NM BONE 3 PHASE STUDY	341	RC	78315	CPT				Both			1085.7	488.57	135.13	1097	253.65							Fee Schedule		277.41							Fee Schedule											135.13							Fee Schedule											977.13							Fee Schedule																				1097							Case Rate																				
NM BONE SCAN	341	RC	78306	CPT				Both			1085.7	488.57	120.94	1097	223.5							Fee Schedule		243.45							Fee Schedule											120.94							Fee Schedule											977.13							Fee Schedule																				1097							Case Rate																				
NM BONE/JOINT LTD AREAS	341	RC	78300	CPT				Both			1085.7	488.57	70.58	1097	170.93							Fee Schedule		186.44							Fee Schedule											70.58							Fee Schedule											977.13							Fee Schedule																				1097							Case Rate																				
NM BONE/JOINT MULTI AREAS	341	RC	78305	CPT				Both			1085.7	488.57	103.79	1097	205.74							Fee Schedule		223.97							Fee Schedule											103.79							Fee Schedule											977.13							Fee Schedule																				1097							Case Rate																				
NM BRAIN COMPLETE	341	RC	78605	CPT				Both			1085.7	488.57	96.19	1097	147.23							Fee Schedule		161.3							Fee Schedule											96.19							Fee Schedule											977.13							Fee Schedule																				1097							Case Rate																				
NM BRAIN LIMITED	341	RC	78601	CPT				Both			1085.7	488.57	96.19	1097	162.08							Fee Schedule		179.16							Fee Schedule											96.19							Fee Schedule											977.13							Fee Schedule																				1097							Case Rate																				
NM BRAIN SCAN	341	RC	78606	CPT				Both			1085.7	488.57	109.55	1097	254.82							Fee Schedule		279.04							Fee Schedule											109.55							Fee Schedule											977.13							Fee Schedule																				1097							Case Rate																				
NM CERETEC WBC SCAN	341	RC	78802	CPT				Both			3916.44	1762.4	156.66	3524.8	241.43							Fee Schedule		262.8							Fee Schedule											156.66							Fee Schedule											3524.8							Fee Schedule																				1097							Case Rate																				
NM CERETEC WBC SCAN	341	RC	78806	CPT				Both			1085.7	488.57	488.57	1097	705.71							Fee Schedule		803.42							Fee Schedule																													977.13							Fee Schedule																				1097							Case Rate																				
NM CYSTOGRAM	341	RC	78740	CPT				Both			1085.7	488.57	60.04	1097	162.95							Fee Schedule		178.51							Fee Schedule											60.04							Fee Schedule											977.13							Fee Schedule																				1097							Case Rate																				
NM ER CALLBACK	341	RC	99220	CPT				Both			99.75	44.89	44.89	1097	203.61							Fee Schedule		73.82							Fee Schedule																													89.78							Fee Schedule																				1097							Case Rate																				
NM GASTRIC EMPTY	341	RC	78264	CPT				Both			1085.7	488.57	116.58	1097	254.24							Fee Schedule		277.09							Fee Schedule											116.58							Fee Schedule											977.13							Fee Schedule																				1097							Case Rate																				
NM GI BLEED	341	RC	78278	CPT				Both			1085.7	488.57	137.8	1097	256.86							Fee Schedule		280.98							Fee Schedule											137.8							Fee Schedule											977.13							Fee Schedule																				1097							Case Rate																				
NM HEPAT W KIN COMP	341	RC	78227	CPT				Both			1470	661.5	296.83	1323	345.52							Fee Schedule		375.99							Fee Schedule											296.83							Fee Schedule											1323							Fee Schedule																				1097							Case Rate																				
NM HEPAT W KINEVAC	341	RC	78227	CPT				Both			1470	661.5	296.83	1323	345.52							Fee Schedule		375.99							Fee Schedule											296.83							Fee Schedule											1323							Fee Schedule																				1097							Case Rate																				
NM HEPATOBILIARY	341	RC	78226	CPT				Both			1085.7	488.57	213.75	1097	251.91							Fee Schedule		274.82							Fee Schedule											213.75							Fee Schedule											977.13							Fee Schedule																				1097							Case Rate																				
NM KID MUL WWO CAP/LAS	341	RC	78709	CPT				Both			1085.7	488.57	125.12	1097	255.69							Fee Schedule		280.66							Fee Schedule											125.12							Fee Schedule											977.13							Fee Schedule																				1097							Case Rate																				
NM KID SGL WWO CAP/LAS	341	RC	78708	CPT				Both			1085.7	488.57	99.95	1097	99.95							Fee Schedule		110.19							Fee Schedule											125.12							Fee Schedule											977.13							Fee Schedule																				1097							Case Rate																				
NM KIDN SGL NO PHARM	341	RC	78707	CPT				Both			1085.7	488.57	126.7	1097	159.46							Fee Schedule		173.97							Fee Schedule											126.7							Fee Schedule											977.13							Fee Schedule																				1097							Case Rate																				
NM LIVER IMAGING STATIC	341	RC	78201	CPT				Both			1085.7	488.57	66.79	1097	143.74							Fee Schedule		158.38							Fee Schedule											66.79							Fee Schedule											977.13							Fee Schedule																				1097							Case Rate																				
NM LIVER/SPLEEN SCAN	341	RC	78215	CPT				Both			1085.7	488.57	83.11	1097	145.48							Fee Schedule		159.35							Fee Schedule											83.11							Fee Schedule											977.13							Fee Schedule																				1097							Case Rate																				
NM LUNG PERF W VENT	341	RC	78582	CPT				Both			1085.7	488.57	198.11	1097	241.14							Fee Schedule		263.78							Fee Schedule											198.11							Fee Schedule											977.13							Fee Schedule																				1097							Case Rate																				
NM LUNG SCAN PERFUSION	341	RC	78597	CPT				Both			1085.7	488.57	118.24	1097	143.44							Fee Schedule		154.94							Fee Schedule											118.24							Fee Schedule											977.13							Fee Schedule																				1097							Case Rate																				
NM LUNG SCAN VENT ONLY	341	RC	78579	CPT				Both			1085.7	488.57	110.3	1097	139.37							Fee Schedule		151.7							Fee Schedule											110.3							Fee Schedule											977.13							Fee Schedule																				1097							Case Rate																				
NM MECKELS SCAN	341	RC	78290	CPT				Both			1085.7	488.57	86.07	1097	254.53							Fee Schedule		278.06							Fee Schedule											86.07							Fee Schedule											977.13							Fee Schedule																				1097							Case Rate																				
NM MUGA GATED HEART	341	RC	78472	CPT				Both			1085.7	488.57	155.09	1097	155.09							Fee Schedule		169.09							Fee Schedule											156.08							Fee Schedule											977.13							Fee Schedule																				1097							Case Rate																				
NM MYCARDIAL PERFUSION	341	RC	78451	CPT				Both			1085.7	488.57	112.25	1097	234.44							Fee Schedule		254.68							Fee Schedule											112.25							Fee Schedule											977.13							Fee Schedule																				1097							Case Rate																				
NM MYO INF (PLAN)	341	RC	78466	CPT				Both			535.5	240.98	74.39	1097	138.79							Fee Schedule		151.56							Fee Schedule											74.39							Fee Schedule											481.95							Fee Schedule																				1097							Case Rate																				
NM MYO PERF (PLAN)	341	RC	78454	CPT				Both			1338.75	602.44	88.01	1204.88	317.29							Fee Schedule		345.79							Fee Schedule											88.01							Fee Schedule											1204.88							Fee Schedule																				1097							Case Rate																				
NM MYOCARDIAL EJECTION	341	RC	78454	CPT				Both			1338.75	602.44	88.01	1204.88	317.29							Fee Schedule		345.79							Fee Schedule											88.01							Fee Schedule											1204.88							Fee Schedule																				1097							Case Rate																				
NM MYOCARDIAL SCAN	341	RC	78453	CPT				Both			1085.7	488.57	104.69	1097	218.14							Fee Schedule		238.77							Fee Schedule											104.69							Fee Schedule											977.13							Fee Schedule																				1097							Case Rate																				
NM PARATHYROID	341	RC	78070	CPT				Both			1085.7	488.57	51.32	1097	223.5							Fee Schedule		243.13							Fee Schedule											51.32							Fee Schedule											977.13							Fee Schedule																				1097							Case Rate																				
NM RAD TC CERETEC	343	RC	A9521	CPT				Both			464.1	208.85	208.85	1450.14	1450.14							Fee Schedule		343.43							Fee Schedule		955.54							Fee Schedule																				417.69							Fee Schedule																																															
NM RADIONUCLIDE 78990	636	RC	A4641	CPT				Both			103.95	46.78	46.78	1066.87		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	76.92							Fee Schedule																				927.71							Fee Schedule		93.56							Fee Schedule		1066.87							Fee Schedule		862.77							Fee Schedule											1066.87							Fee Schedule		862.77							Fee Schedule		
NM RADIONUCLIDE ACUTECK	343	RC	A9504	CPT				Both			688.8	309.96	309.96	619.92	415							Fee Schedule		509.71							Fee Schedule																													619.92							Fee Schedule																																															
NM RADIONUCLIDE CERETEC	343	RC	A9521	CPT				Both			464.1	208.85	208.85	1450.14	1450.14							Fee Schedule		343.43							Fee Schedule		955.54							Fee Schedule																				417.69							Fee Schedule																																															
NM RADIONUCLIDE DTPA	343	RC	A9539	CPT				Both			123.9	55.76	31.21	1066.87	31.21							Fee Schedule		91.69							Fee Schedule																				927.71							Fee Schedule		111.51							Fee Schedule		1066.87							Fee Schedule		862.77							Fee Schedule											1066.87							Fee Schedule		862.77							Fee Schedule		
NM RADIONUCLIDE GA 67	343	RC	A9556	CPT				Both			239.4	107.73	107.73	215.46	119.69							Fee Schedule		177.16							Fee Schedule																													215.46							Fee Schedule																																															
NM RADIONUCLIDE GALIUM	343	RC	A9556	CPT				Both			225.75	101.59	101.59	203.18	119.69							Fee Schedule		167.06							Fee Schedule																													203.18							Fee Schedule																																															
NM RADIONUCLIDE I 123	343	RC	A9516	CPT				Both			123.9	55.76	55.76	180.13	180.13							Fee Schedule		91.69							Fee Schedule																													111.51							Fee Schedule																																															
NM RADIONUCLIDE I 131	636	RC	A9517	CPT				Both			192.15	86.47	24.79	172.94		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."								Other	No Additional Reimbursement 	24.79							Fee Schedule																				172.94							Fee Schedule																																															
NM RADIONUCLIDE I 131	636	RC	A9517	CPT				Both			179.55	80.8	22.39	161.6		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."								Other	No Additional Reimbursement 	24.79							Fee Schedule											24.07							Fee Schedule		161.6							Fee Schedule		27.68							Fee Schedule		22.39							Fee Schedule											27.68							Fee Schedule		22.39							Fee Schedule		
NM RADIONUCLIDE MYOVIEW	343	RC	A9502	CPT				Both			558.6	251.37	22.39	502.74	97.07							Fee Schedule		413.36							Fee Schedule											47.79							Fee Schedule		24.07							Fee Schedule		502.74							Fee Schedule		27.68							Fee Schedule		22.39							Fee Schedule											27.68							Fee Schedule		22.39							Fee Schedule		
NM RADIONUCLIDE PYP	343	RC	A9538	CPT				Both			123.9	55.76	49.8	111.51	49.8							Fee Schedule		91.69							Fee Schedule																													111.51							Fee Schedule																																															
NM RADIONUCLIDE T1 201	343	RC	A9500	CPT				Both			273	122.85	70	245.7	106.32							Fee Schedule		70							Fee Schedule																													245.7							Fee Schedule																																															
NM RADIONUCLIDE TC	343	RC	A9512	CPT				Both			123.9	55.76	0.26	111.51	0.26							Fee Schedule		91.69							Fee Schedule																													111.51							Fee Schedule																																															
NM RADIONUCLIDE TC CHOLETEC	343	RC	A9537	CPT				Both			123.9	55.76	55.1	111.51	55.1							Fee Schedule		91.69							Fee Schedule																													111.51							Fee Schedule																																															
NM RADIONUCLIDE TC DTPA	343	RC	A9539	CPT				Both			102.9	46.31	31.21	92.61	31.21							Fee Schedule		76.15							Fee Schedule																													92.61							Fee Schedule																																															
NM RADIONUCLIDE TC MAA	343	RC	A9540	CPT				Both			123.9	55.76	29.88	111.51	29.88							Fee Schedule		91.69							Fee Schedule																													111.51							Fee Schedule																																															
NM RADIONUCLIDE TC MAG 3	343	RC	A9562	CPT				Both			315	141.75	141.75	771.68	771.68							Fee Schedule		233.1							Fee Schedule																													283.5							Fee Schedule																																															
NM RADIONUCLIDE TC MDP	343	RC	A9503	CPT				Both			150.15	67.57	12.95	135.14	12.95							Fee Schedule		111.11							Fee Schedule											29.02							Fee Schedule											135.14							Fee Schedule																																															
NM RADIONUCLIDE TC SC	343	RC	A9541	CPT				Both			123.9	55.76	53.26	111.51	53.26							Fee Schedule		91.69							Fee Schedule																													111.51							Fee Schedule																																															
NM RADIONUCLIDE THALLIUM	636	RC	A4641	CPT				Both			254.1	114.35	114.35	228.69		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	188.03							Fee Schedule																													228.69							Fee Schedule																																															
NM SENTINEL NODE	341	RC	38792	CPT				Both			1085.7	488.57	49.14	1097	49.14							Fee Schedule		803.42							Fee Schedule																													977.13							Fee Schedule																				1097							Case Rate																				
NM SPE LEXISCAN TRED/REST	341	RC	78452	CPT				Both			1443.75	649.69	217.02	1299.38	338.42							Fee Schedule		368.06							Fee Schedule											217.02							Fee Schedule											1299.38							Fee Schedule																				1097							Case Rate																				
NM SPE PER TRED/REST	341	RC	78452	CPT				Both			1900	855	217.02	1710	338.42							Fee Schedule		368.06							Fee Schedule											217.02							Fee Schedule											1710							Fee Schedule																				1097							Case Rate																				
NM SPEC PER RST ONLY	341	RC	78451	CPT				Both			1085.7	488.57	112.25	1097	234.44							Fee Schedule		254.68							Fee Schedule											112.25							Fee Schedule											977.13							Fee Schedule																				1097							Case Rate																				
NM SPEC PER TRED REST-UNGATED	341	RC	78452	CPT				Both			1443.75	649.69	217.02	1299.38	338.42							Fee Schedule		368.06							Fee Schedule											217.02							Fee Schedule											1299.38							Fee Schedule																				1097							Case Rate																				
NM SPECT BONE SCAN	341	RC	78831	CPT				Both			1085.7	488.57	468.7	1097	517.56							Fee Schedule		576.91							Fee Schedule											468.7							Fee Schedule											977.13							Fee Schedule																				1097							Case Rate																				
NM SPECT BRAIN IMAGING	341	RC	78803	CPT				Both			1085.7	488.57	185.62	1097	249							Fee Schedule		269.94							Fee Schedule											185.62							Fee Schedule											977.13							Fee Schedule																				1097							Case Rate																				
NM SPECT KIDNEY	341	RC	78803	CPT				Both			1085.7	488.57	185.62	1097	249							Fee Schedule		269.94							Fee Schedule											185.62							Fee Schedule											977.13							Fee Schedule																				1097							Case Rate																				
NM SPECT LIVER - TAGGED RBC	341	RC	78803	CPT				Both			1085.7	488.57	185.62	1097	249							Fee Schedule		269.94							Fee Schedule											185.62							Fee Schedule											977.13							Fee Schedule																				1097							Case Rate																				
NM THY SCAN	341	RC	78013	CPT				Both			1085.7	488.57	139.93	1097	148.39							Fee Schedule		162.6							Fee Schedule											139.93							Fee Schedule											977.13							Fee Schedule																				1097							Case Rate																				
NM THY SCAN VASC FLW	341	RC	78013	CPT				Both			1085.7	488.57	139.93	1097	148.39							Fee Schedule		162.6							Fee Schedule											139.93							Fee Schedule											977.13							Fee Schedule																				1097							Case Rate																				
NM THY UP MULTI DET	341	RC	78014	CPT				Both			1085.7	488.57	159.3	1097	185.36							Fee Schedule		202.54							Fee Schedule											159.3							Fee Schedule											977.13							Fee Schedule																				1097							Case Rate																				
NM TUMOR LOCLIZAT SPEC	341	RC	78803	CPT				Both			1085.7	488.57	185.62	1097	249							Fee Schedule		269.94							Fee Schedule											185.62							Fee Schedule											977.13							Fee Schedule																				1097							Case Rate																				
NM ULTRATAG KIT TC-99M RBC	343	RC	A9560	CPT				Both			113.4	51.03	51.03	102.06	93.03							Fee Schedule		83.92							Fee Schedule																													102.06							Fee Schedule																																															
NM VAS FLW ANG/VEN	341	RC	78445	CPT				Both			1085.7	488.57	53.44	1097	138.5							Fee Schedule		151.24							Fee Schedule											53.44							Fee Schedule											977.13							Fee Schedule																				1097							Case Rate																				
NM VEN THROM ACUTE	341	RC	78456	CPT				Both			1085.7	488.57	117.52	1097	223.67							Fee Schedule		244.62							Fee Schedule											117.52							Fee Schedule											977.13							Fee Schedule																				1097							Case Rate																				
"N-METHYLHISTAMINE, 24 HR UR 39559"	301	RC	82542	CPT				Both			800	360	17.34	720	17.34							Fee Schedule		24.09							Fee Schedule		24.81							Fee Schedule		24.09							Fee Schedule											720							Fee Schedule																				24.09							Fee Schedule																				
NOLVADEX 10 MG TAB	250	RC	A9270	CPT				Both			4.35	1.96	0.01	27.7	0.01							Fee Schedule		3.22							Fee Schedule																				24.09							Fee Schedule		3.92							Fee Schedule		27.7							Fee Schedule		22.4							Fee Schedule											27.7							Fee Schedule		22.4							Fee Schedule		
NON STRESS TEST	920	RC	59025	CPT				Both			68.25	30.71	7.2	254	17.4							Fee Schedule		50.51							Fee Schedule											7.2							Fee Schedule											61.43							Fee Schedule																				254							Per Diem																				
FRACTURES OF HIP AND PELVIS WITHOUT MCC					536	DRG		Inpatient			19865.33	8939.4	8939.4	8939.4							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period. 				7984.71	7984.71	7984.71	1 through 10									0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period	
OSTEOMYELITIS WITH MCC					539	DRG		Inpatient			9501.24	4275.56	4275.56	4275.56							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period	
OSTEOMYELITIS WITH CC					540	DRG		Inpatient			30355.19	13659.83	13659.83	13659.83							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period	
NONREBREATHER #HUD1059 MEDLINE	270	RC	A4619	CPT				Both			3	1.35	1.35	2.7	1.56							Fee Schedule		2.22							Fee Schedule		2.65							Fee Schedule																				2.7							Fee Schedule																																															
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TI					543	DRG		Inpatient			25268.66	11370.9	11370.9	11370.9							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0	Fee Schedule	No services provided during 15 month lookback period							0	Fee Schedule	No services provided during 15 month lookback period							0		No services provided during 15 month lookback							0		No services provided during 15 month lookback period							0	Fee Schedule	No services provided during 15 month lookback period	
NOREPINEPHRINE 24H UR 318	301	RC	82384	CPT				Both			149.1	67.1	22.45	134.19	22.45							Fee Schedule		28.06							Fee Schedule		26.01							Fee Schedule		25.25							Fee Schedule											134.19							Fee Schedule																				25.25							Fee Schedule																				
NOREPINEPHRINE 4MG/  D5W 250ML PREMIX	250	RC	J3490	CPT				Both			80.85	36.38	23.48	72.77	52.55							Fee Schedule		59.83							Fee Schedule																				25.25							Fee Schedule		72.77							Fee Schedule		29.04							Fee Schedule		23.48							Fee Schedule											29.04							Fee Schedule		23.48							Fee Schedule		
NOREPINEPHRINE PLASMA 37562	301	RC	82542	CPT				Both			149.1	67.1	17.34	134.19	17.34							Fee Schedule		24.09							Fee Schedule		24.81							Fee Schedule		24.09							Fee Schedule											134.19							Fee Schedule																				24.09							Fee Schedule																				
NORETHINEDRONE/ESTRADIL 1/35 PACKET	250	RC	A9270	CPT				Both			170.1	76.55	0.01	153.09	0.01							Fee Schedule		125.87							Fee Schedule																				24.09							Fee Schedule		153.09							Fee Schedule		27.7							Fee Schedule		22.4							Fee Schedule											27.7							Fee Schedule		22.4							Fee Schedule		
NORIAN DRILLABLE INJECT 07.704.003S	278	RC	C1713	CPT				Both			4110.75	1849.84	1849.84	3699.68		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	3041.96							Fee Schedule																													3699.68							Fee Schedule																																															
NORIAN DRILLABLE PUTTY 07.704.005S	278	RC	C9356	CPT				Both			5780.25	2601.11	2601.11	5202.23		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	4277.39							Fee Schedule																													5202.23							Fee Schedule																																															
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TI					544	DRG		Inpatient			18767.2	8445.24	8445.24	8445.24							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period	
NORMAL SALINE IRRIGATION 250 CC	270	RC						Both			3.15	1.42	1.42	2.84	2.05							Fee Schedule		2.33							Fee Schedule																													2.84							Fee Schedule																																															
NORMODYNE 5 MG	250	RC	A9270	CPT				Both			5.25	2.36	0.01	4.73	0.01							Fee Schedule		3.89							Fee Schedule																													4.73							Fee Schedule																																															
"NOROVIRUS RNA, QUAL PCR 19098"	306	RC	87798	CPT				Both			645	290.25	31.2	580.5	31.2							Fee Schedule		38.99							Fee Schedule		36.14							Fee Schedule		35.09							Fee Schedule											580.5							Fee Schedule																				35.09							Fee Schedule																				
NOROXIN 400 MG	250	RC	A9270	CPT				Both			7.38	3.32	0.01	40.35	0.01							Fee Schedule		5.46							Fee Schedule																				35.09							Fee Schedule		6.64							Fee Schedule		40.35							Fee Schedule		32.63							Fee Schedule											40.35							Fee Schedule		32.63							Fee Schedule		
NORPACE 100 MG CAPS	250	RC	A9270	CPT				Both			1.58	0.71	0.01	1.42	0.01							Fee Schedule		1.17							Fee Schedule																													1.42							Fee Schedule																																															
NORPACE CR 100 MG CAPS	250	RC	A9270	CPT				Both			4.2	1.89	0.01	3.78	0.01							Fee Schedule		3.11							Fee Schedule																													3.78							Fee Schedule																																															
NORPLANT KIT	636	RC	J7306	CPT				Both			618.45	278.3	278.3	556.61		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	457.65							Fee Schedule																													556.61							Fee Schedule																																															
NORTRIPTYLINE 10MG (PAMELOR) CAPSULE	250	RC	A9270	CPT				Both			5.25	2.36	0.01	4.73	0.01							Fee Schedule		3.89							Fee Schedule																													4.73							Fee Schedule																																															
NORTRIPTYLINE 25MG (PAMELOR) CAPSULE	250	RC	A9270	CPT				Both			5.25	2.36	0.01	4.73	0.01							Fee Schedule		3.89							Fee Schedule																													4.73							Fee Schedule																																															
NORTRIPTYLINE PAMELOR 272 SERUM	301	RC	80307	CPT				Both			82.95	37.33	37.33	74.66	51.72							Fee Schedule		64.65							Fee Schedule		64							Fee Schedule		62.14							Fee Schedule											74.66							Fee Schedule																				62.14							Fee Schedule																				
NOSE TO RECTUM	320	RC	76010	CPT				Both			264	118.8	13.85	318	13.85							Fee Schedule		16.43							Fee Schedule											15.04							Fee Schedule		62.14							Fee Schedule		237.6							Fee Schedule		71.46							Fee Schedule		57.79							Fee Schedule		318							Per Diem		71.46							Fee Schedule		57.79							Fee Schedule		
NO-STING SKIN PREP 1OZ SPRAY 66800709	270	RC	A6250	CPT				Both			19	8.55	0.03	17.1	0.03							Fee Schedule		14.06							Fee Schedule																													17.1							Fee Schedule																																															
NOTCH BLASTER 4.0 BLADE	272	RC						Both			269.85	121.43	121.43	242.87	175.4							Fee Schedule		199.69							Fee Schedule																													242.87							Fee Schedule																																															
NOTCHBLASTER ABRADER 7205665 5.5 SMITHNE	272	RC						Both			202.65	91.19	91.19	182.39	131.72							Fee Schedule		149.96							Fee Schedule																													182.39							Fee Schedule																																															
NOVAHISTINE DH:OZ LI	250	RC	A9270	CPT				Both			6.69	3.01	0.01	6.02	0.01							Fee Schedule		4.95							Fee Schedule																													6.02							Fee Schedule																																															
NOVASURE ABLATION KIT #NS2000US (HOLOGIC	272	RC	C1886	CPT				Both			3449.25	1552.16	1101.74	3104.33	1101.74							Fee Schedule		2552.45							Fee Schedule																													3104.33							Fee Schedule																																															
NOVASURE ABLATION KIT NS2013US (NSV5US-0	272	RC	C1886	CPT				Both			4771	2146.95	1101.74	4293.9	1101.74							Fee Schedule		3530.54							Fee Schedule																													4293.9							Fee Schedule																																															
NOVASURE CO2 CARTRIDGE  815012US ( HOLOG	272	RC						Both			34.65	15.59	15.59	31.19	22.52							Fee Schedule		25.64							Fee Schedule																													31.19							Fee Schedule																																															
NOZ STOP	272	RC						Both			48.3	21.74	21.74	43.47	31.4							Fee Schedule		35.74							Fee Schedule																													43.47							Fee Schedule																																															
NS + 20 MEQ KCL/1000ML 2B1764	250	RC	J3480	CPT				Both			47.25	21.26	0.14	42.53	0.14							Fee Schedule		34.97							Fee Schedule		0.14							Fee Schedule		0.27							Fee Schedule											42.53							Fee Schedule																																															
NS 0.45%  250ML	258	RC						Both			27.3	12.29	0.13	24.57	17.75							Fee Schedule		20.2							Fee Schedule																				0.14							Fee Schedule		24.57							Fee Schedule		0.16							Fee Schedule		0.13							Fee Schedule											0.16							Fee Schedule		0.13							Fee Schedule		
NS 0.45%  500ML	258	RC	J7040	CPT				Both			84	37.8	1.29	75.6	1.29							Fee Schedule		62.16							Fee Schedule		1.39							Fee Schedule		14.33							Fee Schedule											75.6							Fee Schedule																																															
NS 0.9%   25ML	270	RC						Both			24.15	10.87	1.26	21.74	15.7							Fee Schedule		17.87							Fee Schedule																				1.35							Fee Schedule		21.74							Fee Schedule		1.55							Fee Schedule		1.26							Fee Schedule											1.55							Fee Schedule		1.26							Fee Schedule		
NS 1/2 + 20 MEQ KCL/1000ML	250	RC	J3480	CPT				Both			47.25	21.26	0.14	42.53	0.14							Fee Schedule		34.97							Fee Schedule		0.14							Fee Schedule		0.27							Fee Schedule											42.53							Fee Schedule																																															
NS 150 ML	258	RC						Both			27.3	12.29	0.13	24.57	17.75							Fee Schedule		20.2							Fee Schedule																				0.14							Fee Schedule		24.57							Fee Schedule		0.16							Fee Schedule		0.13							Fee Schedule											0.16							Fee Schedule		0.13							Fee Schedule		
NS 150 ML PHARMACY	270	RC						Both			18.9	8.51	8.51	17.01	12.29							Fee Schedule		13.99							Fee Schedule																													17.01							Fee Schedule																																															
NS IRRIG. BOTTLE 500ML  2F7123	272	RC						Both			6	2.7	2.7	5.4	3.9							Fee Schedule		4.44							Fee Schedule																													5.4							Fee Schedule																																															
NS IRRIGATION 5000CC	270	RC						Both			33.6	15.12	15.12	30.24	21.84							Fee Schedule		24.86							Fee Schedule																													30.24							Fee Schedule																																															
NS+KCL 40 MEQ/1000 ML	636	RC	J3480	CPT				Both			37.8	17.01	0.14	34.02		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	27.97							Fee Schedule		0.14							Fee Schedule		0.27							Fee Schedule											34.02							Fee Schedule																																															
NTG SPRAY	250	RC	A9270	CPT				Both			70.97	31.94	0.01	63.87	0.01							Fee Schedule		52.52							Fee Schedule																				0.14							Fee Schedule		63.87							Fee Schedule		0.16							Fee Schedule		0.13							Fee Schedule											0.16							Fee Schedule		0.13							Fee Schedule		
NT-PRO BNP EDTA 11188	301	RC	83880	CPT				Both			352.17	158.48	30.17	316.95	30.17							Fee Schedule		39.26							Fee Schedule		40.44							Fee Schedule		39.26							Fee Schedule											316.95							Fee Schedule																				39.26							Fee Schedule																				
NU GAUZE 1/2 PLAIN	272	RC						Both			13.65	6.14	6.14	45.15	8.87							Fee Schedule		10.1							Fee Schedule																				39.26							Fee Schedule		12.29							Fee Schedule		45.15							Fee Schedule		36.51							Fee Schedule											45.15							Fee Schedule		36.51							Fee Schedule		
NU IRON ELIX	250	RC	A9270	CPT				Both			4.68	2.11	0.01	4.21	0.01							Fee Schedule		3.46							Fee Schedule																													4.21							Fee Schedule																																															
NU TRAKE TRACH KIT # B10100  ( SENECA )	272	RC						Both			365.4	164.43	164.43	328.86	237.51							Fee Schedule		270.4							Fee Schedule																													328.86							Fee Schedule																																															
NUCLEOTIDASE 5    671 SERUM	301	RC	83915	CPT				Both			63	28.35	9.91	56.7	9.91							Fee Schedule		12.39							Fee Schedule		11.48							Fee Schedule		11.15							Fee Schedule											56.7							Fee Schedule																				11.15							Fee Schedule																				
NU-GAUZE 1/2  PLAIN (HOME HEALTH)	272	RC						Both			7.35	3.31	3.31	12.82	4.78							Fee Schedule		5.44							Fee Schedule																				11.15							Fee Schedule		6.62							Fee Schedule		12.82							Fee Schedule		10.37							Fee Schedule											12.82							Fee Schedule		10.37							Fee Schedule		
NUROLON 0  C541D	272	RC						Both			39.9	17.96	17.96	35.91	25.94							Fee Schedule		29.53							Fee Schedule																													35.91							Fee Schedule																																															
NUROLON 0  C545D	272	RC						Both			40	18	18	36	26							Fee Schedule		29.6							Fee Schedule																													36							Fee Schedule																																															
NUROLON 0 C527D	272	RC						Both			39.9	17.96	17.96	35.91	25.94							Fee Schedule		29.53							Fee Schedule																													35.91							Fee Schedule																																															
NUSHIELD ALLOGRAFT 3X4 (ORGANOGENESIS)	278	RC	Q4160	CPT				Both			292	131.4	130.95	262.8		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	216.08							Fee Schedule		130.95							Fee Schedule																				262.8							Fee Schedule																																															
NUSHIELD ALLOGRAFT 4X4 (ORGANOGENESIS)	278	RC	Q4160	CPT				Both			219	98.55	98.55	197.1		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	162.06							Fee Schedule		130.95							Fee Schedule											127.14							Fee Schedule		197.1							Fee Schedule		146.21							Fee Schedule		118.24							Fee Schedule											146.21							Fee Schedule		118.24							Fee Schedule		
NUSHIELD ALLOGRAFT 4X6 (ORGANOGENESIS)	278	RC	Q4160	CPT				Both			235	105.75	105.75	211.5		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	173.9							Fee Schedule		130.95							Fee Schedule											127.14							Fee Schedule		211.5							Fee Schedule		146.21							Fee Schedule		118.24							Fee Schedule											146.21							Fee Schedule		118.24							Fee Schedule		
NUTRIHEP 250ML RTU CAN	250	RC	A9270	CPT				Both			45.15	20.32	0.01	146.21	0.01							Fee Schedule		33.41							Fee Schedule																				127.14							Fee Schedule		40.64							Fee Schedule		146.21							Fee Schedule		118.24							Fee Schedule											146.21							Fee Schedule		118.24							Fee Schedule		
NUTRILYTE 20 ML VIAL (ELECTROLYTE CONC.)	250	RC						Both			15.75	7.09	7.09	14.18	10.24							Fee Schedule		11.66							Fee Schedule																													14.18							Fee Schedule																																															
NUTRITIONAL ASSESSMENT EACH 15 MIN	942	RC	97802	CPT				Both			131.25	59.06	22.7	118.13	60							Per Diem		97.13							Fee Schedule											22.7							Fee Schedule											118.13							Fee Schedule																																															
NUTRITIONAL RE ASSESSMENT EA 15 MIN	942	RC	97803	CPT				Both			42	18.9	18.9	60	60							Per Diem		31.08							Fee Schedule											22.7							Fee Schedule											37.8							Fee Schedule																																															
NYLON 0 L886T	272	RC						Both			13.65	6.14	6.14	12.29	8.87							Fee Schedule		10.1							Fee Schedule																													12.29							Fee Schedule																																															
NYLON ER CHARGE	272	RC						Both			13.65	6.14	6.14	12.29	8.87							Fee Schedule		10.1							Fee Schedule																													12.29							Fee Schedule																																															
NYSTATIN CREAM - 15 GM TUBE	250	RC	A9270	CPT				Both			55.65	25.04	0.01	50.09	0.01							Fee Schedule		41.18							Fee Schedule																													50.09							Fee Schedule																																															
NYSTATIN OINTMENT- 15 GM TUBE	250	RC	A9270	CPT				Both			55.65	25.04	0.01	50.09	0.01							Fee Schedule		41.18							Fee Schedule																													50.09							Fee Schedule																																															
NYSTATIN ORAL SUSP 5ML UD	250	RC	A9270	CPT				Both			6.81	3.06	0.01	6.13	0.01							Fee Schedule		5.04							Fee Schedule																													6.13							Fee Schedule																																															
NYSTATIN ORAL SUSPENSION- 60ML BOTTLE	250	RC	A9270	CPT				Both			53.33	24	0.01	48	0.01							Fee Schedule		39.46							Fee Schedule																													48							Fee Schedule																																															
NYSTATIN/TRIAMCINOLONE ACET CREAM- 15GM	250	RC	A9270	CPT				Both			14.49	6.52	0.01	13.04	0.01							Fee Schedule		10.72							Fee Schedule																													13.04							Fee Schedule																																															
NYSTATIN/TRIAMCINOLONE ACET CREAM-60GM	250	RC	A9270	CPT				Both			37.8	17.01	0.01	34.02	0.01							Fee Schedule		27.97							Fee Schedule																													34.02							Fee Schedule																																															
NYSTATIN/TRIAMCINOLONE ACET OINT -15GM	250	RC	A9270	CPT				Both			39.12	17.6	0.01	35.21	0.01							Fee Schedule		28.95							Fee Schedule																													35.21							Fee Schedule																																															
NYSTOP TOP POWDER 100000 UNITS/GM-60GM	250	RC	A9270	CPT				Both			166.32	74.84	0.01	149.69	0.01							Fee Schedule		123.08							Fee Schedule																													149.69							Fee Schedule																																															
O2 SUPPLY TUBING #HUD1680 MEDLINE	270	RC						Both			7	3.15	3.15	6.3	4.55							Fee Schedule		5.18							Fee Schedule																													6.3							Fee Schedule																																															
OASIS WOUND MATRIX 3X3.5CM 8213-1000-33	278	RC	Q4102	CPT				Both			31	13.95	13.95	130.95		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	22.94							Fee Schedule		130.95							Fee Schedule																				27.9							Fee Schedule																																															
OB PACK DEL RM #DYNJP6010 (MEDLINE)	270	RC						Both			41	18.45	18.45	146.21	26.65							Fee Schedule		30.34							Fee Schedule																				127.14							Fee Schedule		36.9							Fee Schedule		146.21							Fee Schedule		118.24							Fee Schedule											146.21							Fee Schedule		118.24							Fee Schedule		
OB PADS NON241286  CONCORDANCE	270	RC						Both			6	2.7	2.7	5.4	3.9							Fee Schedule		4.44							Fee Schedule																													5.4							Fee Schedule																																															
OB STRESS TEST	920	RC	59025	CPT				Both			150.15	67.57	7.2	254	17.4							Fee Schedule		111.11							Fee Schedule											7.2							Fee Schedule											135.14							Fee Schedule																				254							Per Diem																				
OC AZITHROMYCIN 250 MG TABLET UD	250	RC	A9270	CPT				Both			8.4	3.78	0.01	7.56	0.01							Fee Schedule		6.22							Fee Schedule																													7.56							Fee Schedule																																															
OCCLUSIVE CUFF AMS800 SPHINCTER 72404133	278	RC	C1815	CPT				Both			24420	10989	565.84	21978		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	18070.8							Fee Schedule																				608.43							Fee Schedule		21978							Fee Schedule		699.69							Fee Schedule		565.84							Fee Schedule											699.69							Fee Schedule		565.84							Fee Schedule		
OCCULT BLOOD DIAGNOSTIC	301	RC	82272	CPT				Both			36.75	16.54	3.05	33.08	3.05							Fee Schedule		4.23							Fee Schedule		4.36							Fee Schedule		4.23							Fee Schedule											33.08							Fee Schedule																				4.23							Fee Schedule																				
OCCULT BLOOD OTHER SOURCES	301	RC	82271	CPT				Both			36.75	16.54	3.83	33.08	3.83							Fee Schedule		5.32							Fee Schedule		5.48							Fee Schedule		5.32							Fee Schedule											33.08							Fee Schedule																				5.32							Fee Schedule																				
OCCULT BLOOD REPEAT STOOL (1-3 SPEC)	300	RC	82270	CPT				Both			36.75	16.54	3.15	33.08	3.15							Fee Schedule		4.38							Fee Schedule		4.51							Fee Schedule		4.38							Fee Schedule											33.08							Fee Schedule																				4.38							Fee Schedule																				
OCCULT BLOOD SCREEN STOOL	300	RC	82270	CPT				Both			36.75	16.54	3.15	33.08	3.15							Fee Schedule		4.38							Fee Schedule		4.51							Fee Schedule		4.38							Fee Schedule		4.23							Fee Schedule		33.08							Fee Schedule		4.86							Fee Schedule		3.93							Fee Schedule		4.38							Fee Schedule		4.86							Fee Schedule		3.93							Fee Schedule		
OCL SPLINT 2 PER FT	271	RC						Both			9.71	4.37	4.37	8.74	6.31							Fee Schedule		7.19							Fee Schedule																				5.32							Fee Schedule		8.74							Fee Schedule		6.12							Fee Schedule		4.95							Fee Schedule											6.12							Fee Schedule		4.95							Fee Schedule		
OCL SPLINT 3 PER FT	270	RC						Both			14.7	6.62	4.07	13.23	9.56							Fee Schedule		10.88							Fee Schedule																				4.38							Fee Schedule		13.23							Fee Schedule		5.04							Fee Schedule		4.07							Fee Schedule											5.04							Fee Schedule		4.07							Fee Schedule		
OCL SPLINT 4 PER FT	270	RC						Both			17.85	8.03	4.07	16.07	11.6							Fee Schedule		13.21							Fee Schedule																				4.38							Fee Schedule		16.07							Fee Schedule		5.04							Fee Schedule		4.07							Fee Schedule											5.04							Fee Schedule		4.07							Fee Schedule		
OCL SPLINT 5 PER FT	274	RC	A4580	CPT				Both			22.05	9.92	9.92	23.72		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	16.32							Fee Schedule											23.72							Fee Schedule											19.85							Fee Schedule																																															
OCTAGAM 5%  10 GMS/200 ML	636	RC	J1568	CPT				Both			4398.45	1979.3	47.03	3958.61		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	47.03							Fee Schedule		48.81							Fee Schedule																				3958.61							Fee Schedule																																															
OCTAGAM 5%  5GMS/100 ML	636	RC	J1568	CPT				Both			2199.75	989.89	47.03	1979.78		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	47.03							Fee Schedule		48.81							Fee Schedule																				1979.78							Fee Schedule																																															
OCTREOTIDE (SANDOSTATIN) 100 MCG/ML -1ML	250	RC	J2354	CPT				Both			25.2	11.34	0.61	22.68	0.94							Fee Schedule		18.65							Fee Schedule		0.61							Fee Schedule																				22.68							Fee Schedule																																															
OCTREOTIDE (SANDOSTATIN) 1000 MCG/ML-5ML	636	RC	J2354	CPT				Both			375.9	169.16	0.61	338.31		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	278.17							Fee Schedule		0.61							Fee Schedule											47.39							Fee Schedule		338.31							Fee Schedule		54.49							Fee Schedule		44.07							Fee Schedule											54.49							Fee Schedule		44.07							Fee Schedule		
OCTREOTIDE (SANDOSTATIN) 200 MCG/ML-5ML	636	RC	J2354	CPT				Both			357.75	160.99	0.61	321.98		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	264.74							Fee Schedule		0.61							Fee Schedule											47.39							Fee Schedule		321.98							Fee Schedule		54.49							Fee Schedule		44.07							Fee Schedule											54.49							Fee Schedule		44.07							Fee Schedule		
OCTREOTIDE (SANDOSTATIN) 200 MCG/ML-5ML	636	RC	J2354	CPT				Both			826.88	372.1	0.55	744.19		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	611.89							Fee Schedule		0.61							Fee Schedule											0.6							Fee Schedule		744.19							Fee Schedule		0.69							Fee Schedule		0.55							Fee Schedule											0.69							Fee Schedule		0.55							Fee Schedule		
OCTREOTIDE 600MCG/NS 250ML DRIP	250	RC	J2354	CPT				Both			49.35	22.21	0.55	44.42	0.94							Fee Schedule		36.52							Fee Schedule		0.61							Fee Schedule											0.6							Fee Schedule		44.42							Fee Schedule		0.69							Fee Schedule		0.55							Fee Schedule											0.69							Fee Schedule		0.55							Fee Schedule		
OFFLOADING ALL PURPOSE BOOT LG #APQ3B	274	RC	L4387	CPT				Both			55	24.75	0.55	201.77		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	40.7							Fee Schedule		201.77							Fee Schedule											0.6							Fee Schedule		49.5							Fee Schedule		0.69							Fee Schedule		0.55							Fee Schedule											0.69							Fee Schedule		0.55							Fee Schedule		
OFFLOADING ALL PURPOSE BOOT MD #APQ2B	274	RC	L4387	CPT				Both			55	24.75	0.55	201.77		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	40.7							Fee Schedule		201.77							Fee Schedule											0.6							Fee Schedule		49.5							Fee Schedule		0.69							Fee Schedule		0.55							Fee Schedule											0.69							Fee Schedule		0.55							Fee Schedule		
OFFLOADING ALL PURPOSE BOOT SM #APQ1B	274	RC	L4387	CPT				Both			55	24.75	0.55	201.77		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	40.7							Fee Schedule		201.77							Fee Schedule											0.6							Fee Schedule		49.5							Fee Schedule		0.69							Fee Schedule		0.55							Fee Schedule											0.69							Fee Schedule		0.55							Fee Schedule		
OFFLOADING ALL PURPOSE BOOT XL #APQ4B	274	RC	L4387	CPT				Both			55	24.75	24.75	225.27		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	40.7							Fee Schedule		201.77							Fee Schedule											195.89							Fee Schedule		49.5							Fee Schedule		225.27							Fee Schedule		182.18							Fee Schedule											225.27							Fee Schedule		182.18							Fee Schedule		
OFLOXACIN 0.3% (FLOXIN) OTIC DROPS	250	RC	A9270	CPT				Both			58.09	26.14	0.01	225.27	0.01							Fee Schedule		42.99							Fee Schedule																				195.89							Fee Schedule		52.28							Fee Schedule		225.27							Fee Schedule		182.18							Fee Schedule											225.27							Fee Schedule		182.18							Fee Schedule		
OFLOXACIN 0.3% OPTH.SOL.-5ML	250	RC	A9270	CPT				Both			131.39	59.13	0.01	225.27	0.01							Fee Schedule		97.23							Fee Schedule																				195.89							Fee Schedule		118.25							Fee Schedule		225.27							Fee Schedule		182.18							Fee Schedule											225.27							Fee Schedule		182.18							Fee Schedule		
OGEN 0.625 MG TABS	250	RC	A9270	CPT				Both			5.25	2.36	0.01	225.27	0.01							Fee Schedule		3.89							Fee Schedule																				195.89							Fee Schedule		4.73							Fee Schedule		225.27							Fee Schedule		182.18							Fee Schedule											225.27							Fee Schedule		182.18							Fee Schedule		
OIL EMULSION DRESSING 3X3 #6112	272	RC	A6222	CPT				Both			1	0.45	0.45	3.13	1.92							Fee Schedule		0.74							Fee Schedule		3.13							Fee Schedule		2.4							Fee Schedule											0.9							Fee Schedule																																															
OIL EMULSION DRESSING 3X8 #CUR250381Z	272	RC	A6223	CPT				Both			2	0.9	0.9	3.56	2.18							Fee Schedule		1.48							Fee Schedule		3.56							Fee Schedule		2.73							Fee Schedule											1.8							Fee Schedule																																															
OLANZAPINE  70073	301	RC	80299	CPT				Both			222	99.9	13.42	199.8	13.42							Fee Schedule		18.64							Fee Schedule		19.2							Fee Schedule		18.64							Fee Schedule											199.8							Fee Schedule																				18.64							Fee Schedule																				
OLANZapine (ZYPREXA)  2.5 MG TABLET	250	RC	A9270	CPT				Both			17.85	8.03	0.01	16.07	0.01							Fee Schedule		13.21							Fee Schedule																				3.04							Fee Schedule		16.07							Fee Schedule		3.5							Fee Schedule		2.83							Fee Schedule											3.5							Fee Schedule		2.83							Fee Schedule		
OLANZapine 5MG ODT (ZYPREXA)	250	RC	A9270	CPT				Both			45.15	20.32	0.01	40.64	0.01							Fee Schedule		33.41							Fee Schedule																				3.46							Fee Schedule		40.64							Fee Schedule		3.98							Fee Schedule		3.22							Fee Schedule											3.98							Fee Schedule		3.22							Fee Schedule		
OLANZAPINE IM PWD FOR SOLN 10MG	636	RC	J2359	CPT				Both			127.59	57.42	0.71	114.83		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	94.42							Fee Schedule		0.71							Fee Schedule											18.64							Fee Schedule		114.83							Fee Schedule		21.44							Fee Schedule		17.34							Fee Schedule											21.44							Fee Schedule		17.34							Fee Schedule		
OLANZAPINE ZYDIS 5 MG TABLET UD	250	RC	A9270	CPT				Both			26.78	12.05	0.01	24.1	0.01							Fee Schedule		19.82							Fee Schedule																													24.1							Fee Schedule																																															
OLIGOCLONAL BAND 674 CSF	301	RC	83916	CPT				Both			110.25	49.61	19.72	99.23	19.72							Fee Schedule		27.39							Fee Schedule		28.21							Fee Schedule		27.39							Fee Schedule											99.23							Fee Schedule																				27.39							Fee Schedule																				
OLIVE TIP 4FR	272	RC						Both			135.45	60.95	0.64	121.91	88.04							Fee Schedule		100.23							Fee Schedule																				0.69							Fee Schedule		121.91							Fee Schedule		0.8							Fee Schedule		0.64							Fee Schedule											0.8							Fee Schedule		0.64							Fee Schedule		
OLMESARTAN MEDOXOMIL 20MG (BENICAR)  TAB	250	RC	A9270	CPT				Both			19.95	8.98	0.01	17.96	0.01							Fee Schedule		14.76							Fee Schedule																													17.96							Fee Schedule																																															
OLUMPUS GRASPING FORCEP FG-46L-1	272	RC						Both			1596	718.2	25.47	1436.4	1037.4							Fee Schedule		1181.04							Fee Schedule																				27.39							Fee Schedule		1436.4							Fee Schedule		31.5							Fee Schedule		25.47							Fee Schedule											31.5							Fee Schedule		25.47							Fee Schedule		
OLUMPUS POLYGRAB TRIP0D FORCEP FG-600U	272	RC						Both			1080	486	486	972	702							Fee Schedule		799.2							Fee Schedule																													972							Fee Schedule																																															
OLYMPUS 3 LUMEN EXTRACTION BALLOON	272	RC						Both			355.95	160.18	160.18	320.36	231.37							Fee Schedule		263.4							Fee Schedule																													320.36							Fee Schedule																																															
OLYMPUS ASPIRATION NEEDLE W/HOLE #NA-1C1	272	RC						Both			152.25	68.51	68.51	137.03	98.96							Fee Schedule		112.67							Fee Schedule																													137.03							Fee Schedule																																															
OLYMPUS ASPIRATION NEEDLE W/HOLE #NA-2C1	272	RC						Both			152.25	68.51	68.51	137.03	98.96							Fee Schedule		112.67							Fee Schedule																													137.03							Fee Schedule																																															
OLYMPUS BOTTLE TO BOTTLE TUBING 20714	272	RC	A7002	CPT				Both			6	2.7	2.7	5.4	2.93							Fee Schedule		4.44							Fee Schedule		4.79							Fee Schedule																				5.4							Fee Schedule																																															
OLYMPUS CHANNEL TUBE MAJ-1651	272	RC						Both			56	25.2	25.2	50.4	36.4							Fee Schedule		41.44							Fee Schedule																													50.4							Fee Schedule																																															
OLYMPUS ELECTRODE #A22201C	272	RC						Both			426.3	191.84	191.84	383.67	277.1							Fee Schedule		315.46							Fee Schedule																													383.67							Fee Schedule																																															
OLYMPUS ELECTRODE ANGLED #A22231C	272	RC						Both			331.8	149.31	4.32	298.62	215.67							Fee Schedule		245.53							Fee Schedule																				4.65							Fee Schedule		298.62							Fee Schedule		5.35							Fee Schedule		4.32							Fee Schedule											5.35							Fee Schedule		4.32							Fee Schedule		
OLYMPUS FLOWER BASKET FG-V421PR	272	RC						Both			652.05	293.42	293.42	586.85	423.83							Fee Schedule		482.52							Fee Schedule																													586.85							Fee Schedule																																															
OLYMPUS GRASPING FORCEPS FG-44NR-1	272	RC						Both			649	292.05	292.05	584.1	421.85							Fee Schedule		480.26							Fee Schedule																													584.1							Fee Schedule																																															
OLYMPUS GRASPING FORCEPS FG-51D (DISC)	272	RC						Both			635.25	285.86	285.86	571.73	412.91							Fee Schedule		470.09							Fee Schedule																													571.73							Fee Schedule																																															
OLYMPUS GRASPING FORCEPS FG-52D	272	RC						Both			673	302.85	302.85	605.7	437.45							Fee Schedule		498.02							Fee Schedule																													605.7							Fee Schedule																																															
OLYMPUS GRASPING FORCEPS FG-54D	272	RC						Both			718	323.1	323.1	646.2	466.7							Fee Schedule		531.32							Fee Schedule																													646.2							Fee Schedule																																															
OLYMPUS INTEGRATED TUBING WA40634A	272	RC	A7002	CPT				Both			243	109.35	2.93	218.7	2.93							Fee Schedule		179.82							Fee Schedule		4.79							Fee Schedule																				218.7							Fee Schedule																																															
OLYMPUS LOWER CLIP HX-201UR-135.B	278	RC	C1760	CPT				Both			199.5	89.78	89.78	179.55		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	147.63							Fee Schedule																													179.55							Fee Schedule																																															
OLYMPUS POLY LOOP HX-400U-30	272	RC						Both			315	141.75	141.75	283.5	204.75							Fee Schedule		233.1							Fee Schedule																													283.5							Fee Schedule																																															
OLYMPUS POLY LOOP HX-400U-30	272	RC						Both			345	155.25	4.32	310.5	224.25							Fee Schedule		255.3							Fee Schedule																				4.65							Fee Schedule		310.5							Fee Schedule		5.35							Fee Schedule		4.32							Fee Schedule											5.35							Fee Schedule		4.32							Fee Schedule		
OLYMPUS QUICK CLIP #HX-200L-135.B	278	RC	C1760	CPT				Both			152.25	68.51	68.51	137.03		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	112.67							Fee Schedule																													137.03							Fee Schedule																																															
OLYMPUS QUICK CLIP #HX-200U-135.B	278	RC						Both			152.25	68.51	68.51	137.03		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	112.67							Fee Schedule																													137.03							Fee Schedule																																															
OLYMPUS QUICK CLIP PRO  HX-202UR.A	272	RC						Both			475.65	214.04	214.04	428.09	309.17							Fee Schedule		351.98							Fee Schedule																													428.09							Fee Schedule																																															
OLYMPUS RETRIEVAL BASKET FG-401Q	272	RC						Both			568.05	255.62	255.62	511.25	369.23							Fee Schedule		420.36							Fee Schedule																													511.25							Fee Schedule																																															
OLYMPUS UPPER CLIP HX-201LR-135.B	278	RC	C1760	CPT				Both			199.5	89.78	89.78	179.55		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	147.63							Fee Schedule																													179.55							Fee Schedule																																															
OLYMPUS VISIGLIDE GUIDEWIRE #G-240-2545A	272	RC						Both			567	255.15	255.15	510.3	368.55							Fee Schedule		419.58							Fee Schedule																													510.3							Fee Schedule																																															
OLYMPUS VISIGLIDE GUIDEWIRE #G-240-2545S	272	RC						Both			567	255.15	255.15	510.3	368.55							Fee Schedule		419.58							Fee Schedule																													510.3							Fee Schedule																																															
OMEPRAZOLE 20 MG CAPSULE UD	250	RC	A9270	CPT				Both			14.7	6.62	0.01	13.23	0.01							Fee Schedule		10.88							Fee Schedule																													13.23							Fee Schedule																																															
OMNI 2 INSERT	278	RC	C1776	CPT				Both			1348.2	606.69	606.69	1213.38		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	997.67							Fee Schedule																													1213.38							Fee Schedule																																															
OMNIFLUSH CATH. VASCULAR 5 FR. 10732201	272	RC	C1887	CPT				Both			53	23.85	23.85	47.7	43.86							Fee Schedule		39.22							Fee Schedule																													47.7							Fee Schedule																																															
OMNIFLUSH CATH. VASCULAR 70CM 13709701	272	RC	C1887	CPT				Both			763	343.35	43.86	686.7	43.86							Fee Schedule		564.62							Fee Schedule																													686.7							Fee Schedule																																															
OMNIPAQUE 240MG/ML-10ML VIAL	254	RC	A9575	CPT				Both			156.69	70.51	0.09	141.02	0.18							Fee Schedule		115.95							Fee Schedule		0.09							Fee Schedule																				141.02							Fee Schedule																																															
OMNIPAQUE 350 100 ML	254	RC	A9575	CPT				Both			311	139.95	0.09	279.9	0.18							Fee Schedule		230.14							Fee Schedule		0.09							Fee Schedule																				279.9							Fee Schedule																																															
ONDANSETRON (ZOFRAN) 4 MG/5 ML ORAL SOL	250	RC	S0119	CPT				Both			48.3	21.74	0.55	43.47	0.55							Fee Schedule		35.74							Fee Schedule																													43.47							Fee Schedule																																															
ONDANSETRON 2 MG/ML-2ML VIAL	636	RC	J2405	CPT				Both			75.76	34.09	0.08	68.18		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	56.06							Fee Schedule		0.09							Fee Schedule		7.86							Fee Schedule		0.09							Fee Schedule		68.18							Fee Schedule		0.1							Fee Schedule		0.08							Fee Schedule											0.1							Fee Schedule		0.08							Fee Schedule		
ONDANSETRON 4 MG TABLET	250	RC	A9270	CPT				Both			42.44	19.1	0.01	38.2	0.01							Fee Schedule		31.41							Fee Schedule																				0.09							Fee Schedule		38.2							Fee Schedule		0.1							Fee Schedule		0.08							Fee Schedule											0.1							Fee Schedule		0.08							Fee Schedule		
ONDANSETRON 4 MG/2ML (ZOFRAN) INJECTION	636	RC	J2405	CPT				Both			12.6	5.67	0.09	11.34		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	9.32							Fee Schedule		0.09							Fee Schedule		7.86							Fee Schedule											11.34							Fee Schedule																																															
ONDANSETRON 4MG TABLET	250	RC	S0119	CPT				Both			6.3	2.84	0.08	5.67	0.55							Fee Schedule		4.66							Fee Schedule																				0.09							Fee Schedule		5.67							Fee Schedule		0.1							Fee Schedule		0.08							Fee Schedule											0.1							Fee Schedule		0.08							Fee Schedule		
ONDANSETRON ODT (ZOFRAN) 4MG DISINT TAB	250	RC	S0119	CPT				Both			70.35	31.66	0.55	63.32	0.55							Fee Schedule		52.06							Fee Schedule																													63.32							Fee Schedule																																															
ONE HOUR NEBULIZER 002533	271	RC						Both			24	10.8	0.08	21.6	15.6							Fee Schedule		17.76							Fee Schedule																				0.09							Fee Schedule		21.6							Fee Schedule		0.1							Fee Schedule		0.08							Fee Schedule											0.1							Fee Schedule		0.08							Fee Schedule		
ONE-A-DAY MULTI-VITAMIN	250	RC	A9270	CPT				Both			1.58	0.71	0.01	1.42	0.01							Fee Schedule		1.17							Fee Schedule																													1.42							Fee Schedule																																															
ONGLYZA 2.5 TABLET	250	RC	A9270	CPT				Both			27.3	12.29	0.01	24.57	0.01							Fee Schedule		20.2							Fee Schedule																													24.57							Fee Schedule																																															
OPERATIVE CHOLANGIOGRAM	329	RC	74300	CPT				Both			429.45	193.25	24.67	386.51	27.63							Fee Schedule		24.67							Fee Schedule											37.68							Fee Schedule											386.51							Fee Schedule																				318							Per Diem																				
"OPIATE, CONFIRMATION, URINE 15860"	301	RC	80365	CPT				Both			120.75	54.34	0.01	108.68	0.01							Fee Schedule									Other	No Additional Reimbursement 																												108.68							Fee Schedule																																															
OPTICELL SILVER DRESSING 4X5 #MSC9845EPZ	270	RC						Both			23	10.35	10.35	20.7	14.95							Fee Schedule		17.02							Fee Schedule																													20.7							Fee Schedule																																															
OPTICELL SILVER ROPE 18  #MSC9818RZ	272	RC	A6199	CPT				Both			28	12.6	4.76	25.2	4.76							Fee Schedule		20.72							Fee Schedule		7.75							Fee Schedule		5.95							Fee Schedule											25.2							Fee Schedule																																															
OPTIFOAM DRESSING 3X3  #MSCEX33EPZ	272	RC	A6212	CPT				Both			6	2.7	2.7	14.26	8.74							Fee Schedule		4.44							Fee Schedule		14.26							Fee Schedule		10.93							Fee Schedule											5.4							Fee Schedule																																															
OPTI-ICE CHILL UNIT (SAMMONS-PRESTON)	270	RC						Both			561.75	252.79	252.79	505.58	365.14							Fee Schedule		415.7							Fee Schedule																													505.58							Fee Schedule																																															
OPTI-ICE SHOULDER PAD (SAMMONS-PRESTON)	270	RC						Both			216.3	97.34	6.99	194.67	140.6							Fee Schedule		160.06							Fee Schedule																				7.52							Fee Schedule		194.67							Fee Schedule		8.65							Fee Schedule		6.99							Fee Schedule											8.65							Fee Schedule		6.99							Fee Schedule		
OPTILOCK 4X4  #MSC6444EPZ	272	RC	A6196	CPT				Both			6	2.7	2.7	15.92	6.62							Fee Schedule		4.44							Fee Schedule		10.8							Fee Schedule		8.28							Fee Schedule		13.84							Fee Schedule		5.4							Fee Schedule		15.92							Fee Schedule		12.87							Fee Schedule											15.92							Fee Schedule		12.87							Fee Schedule		
OPTILOCK 6.5X10  #MSC64610EPZ	272	RC	A6198	CPT				Both			15	6.75	6.75	20	20							Fee Schedule		11.1							Fee Schedule																													13.5							Fee Schedule																																															
OPTILOCK DRESSING 8X12  #MSC64812EPZ	272	RC	A6198	CPT				Both			15	6.75	6.75	20	20							Fee Schedule		11.1							Fee Schedule																													13.5							Fee Schedule																																															
OPTIMENTAL FEEDING	250	RC						Both			108.15	48.67	9.76	97.34	70.3							Fee Schedule		80.03							Fee Schedule																				10.49							Fee Schedule		97.34							Fee Schedule		12.06							Fee Schedule		9.76							Fee Schedule											12.06							Fee Schedule		9.76							Fee Schedule		
OPTIRAY 300- 50 ML	254	RC	Q9967	CPT				Both			164.85	74.18	0.12	148.37	0.12							Fee Schedule		121.99							Fee Schedule		0.16							Fee Schedule																				148.37							Fee Schedule																																															
OPTIRAY 300-100 ML	255	RC	Q9967	CPT				Both			46	20.7	0.12	41.4	0.12							Fee Schedule		34.04							Fee Schedule		0.16							Fee Schedule																				41.4							Fee Schedule																																															
OPTIRAY 320-100 ML	272	RC	Q9967	CPT				Both			47	21.15	0.12	42.3	0.12							Fee Schedule		34.78							Fee Schedule		0.16							Fee Schedule																				42.3							Fee Schedule																																															
OPTIRAY 320-100 ML	254	RC	Q9967	CPT				Both			329.7	148.37	0.12	296.73	0.12							Fee Schedule		243.98							Fee Schedule		0.16							Fee Schedule											0.16							Fee Schedule		296.73							Fee Schedule		0.18							Fee Schedule		0.14							Fee Schedule											0.18							Fee Schedule		0.14							Fee Schedule		
OPTIRAY 320-125 ML	636	RC	Q9967	CPT				Both			226.8	102.06	0.14	204.12		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	167.83							Fee Schedule		0.16							Fee Schedule											0.16							Fee Schedule		204.12							Fee Schedule		0.18							Fee Schedule		0.14							Fee Schedule											0.18							Fee Schedule		0.14							Fee Schedule		
OPTIRAY 320-125 ML	254	RC	Q9967	CPT				Both			329.7	148.37	0.12	296.73	0.12							Fee Schedule		243.98							Fee Schedule		0.16							Fee Schedule											0.16							Fee Schedule		296.73							Fee Schedule		0.18							Fee Schedule		0.14							Fee Schedule											0.18							Fee Schedule		0.14							Fee Schedule		
OPTIRAY 320-125 ML PREFILLED 132387	272	RC	Q9967	CPT				Both			90	40.5	0.12	81	0.12							Fee Schedule		66.6							Fee Schedule		0.16							Fee Schedule											0.16							Fee Schedule		81							Fee Schedule		0.18							Fee Schedule		0.14							Fee Schedule											0.18							Fee Schedule		0.14							Fee Schedule		
OPTIRAY 320-150ML VIALS 222396	255	RC	Q9967	CPT				Both			81	36.45	0.12	72.9	0.12							Fee Schedule		59.94							Fee Schedule		0.16							Fee Schedule											0.16							Fee Schedule		72.9							Fee Schedule		0.18							Fee Schedule		0.14							Fee Schedule											0.18							Fee Schedule		0.14							Fee Schedule		
OPTIRAY 320-50 ML  1323-52	272	RC	Q9967	CPT				Both			36	16.2	0.12	32.4	0.12							Fee Schedule		26.64							Fee Schedule		0.16							Fee Schedule											0.16							Fee Schedule		32.4							Fee Schedule		0.18							Fee Schedule		0.14							Fee Schedule											0.18							Fee Schedule		0.14							Fee Schedule		
OPTIRAY 320-50 ML PREFILLED 132352	255	RC	Q9967	CPT				Both			36	16.2	0.12	32.4	0.12							Fee Schedule		26.64							Fee Schedule		0.16							Fee Schedule											0.16							Fee Schedule		32.4							Fee Schedule		0.18							Fee Schedule		0.14							Fee Schedule											0.18							Fee Schedule		0.14							Fee Schedule		
OPTIRAY 350-100 ML 133311	255	RC	Q9967	CPT				Both			54	24.3	0.12	48.6	0.12							Fee Schedule		39.96							Fee Schedule		0.16							Fee Schedule											0.16							Fee Schedule		48.6							Fee Schedule		0.18							Fee Schedule		0.14							Fee Schedule											0.18							Fee Schedule		0.14							Fee Schedule		
OPTIRAY 350-100 ML PREFILLED 133390	255	RC	Q9967	CPT				Both			72	32.4	0.12	64.8	0.12							Fee Schedule		53.28							Fee Schedule		0.16							Fee Schedule											0.16							Fee Schedule		64.8							Fee Schedule		0.18							Fee Schedule		0.14							Fee Schedule											0.18							Fee Schedule		0.14							Fee Schedule		
OPTIRAY 350-125 ML PREFILLED 133387	255	RC	Q9967	CPT				Both			90	40.5	0.12	81	0.12							Fee Schedule		66.6							Fee Schedule		0.16							Fee Schedule											0.16							Fee Schedule		81							Fee Schedule		0.18							Fee Schedule		0.14							Fee Schedule											0.18							Fee Schedule		0.14							Fee Schedule		
OPTIRAY BULK 350 6X500ML BOTTLES 235617	255	RC	Q9967	CPT				Both			36	16.2	0.12	32.4	0.12							Fee Schedule		26.64							Fee Schedule		0.16							Fee Schedule											0.16							Fee Schedule		32.4							Fee Schedule		0.18							Fee Schedule		0.14							Fee Schedule											0.18							Fee Schedule		0.14							Fee Schedule		
OPTISTAR ELITE DUAL MR SYRINGE 234158	272	RC						Both			41	18.45	0.14	36.9	26.65							Fee Schedule		30.34							Fee Schedule																				0.16							Fee Schedule		36.9							Fee Schedule		0.18							Fee Schedule		0.14							Fee Schedule											0.18							Fee Schedule		0.14							Fee Schedule		
OPTISTAR ELITE DUAL MR SYRINGE 801800B	272	RC						Both			41	18.45	0.14	36.9	26.65							Fee Schedule		30.34							Fee Schedule																				0.16							Fee Schedule		36.9							Fee Schedule		0.18							Fee Schedule		0.14							Fee Schedule											0.18							Fee Schedule		0.14							Fee Schedule		
OPTIVANTAGE CONTRAST TRANSFER SET 810551	272	RC						Both			13	5.85	0.14	11.7	8.45							Fee Schedule		9.62							Fee Schedule																				0.16							Fee Schedule		11.7							Fee Schedule		0.18							Fee Schedule		0.14							Fee Schedule											0.18							Fee Schedule		0.14							Fee Schedule		
ORAJEL (BABY) 7.5%- 9.4GM TUBE	250	RC	A9270	CPT				Both			13.42	6.04	0.01	12.08	0.01							Fee Schedule		9.93							Fee Schedule																													12.08							Fee Schedule																																															
ORAJEL EXTRA STRENGTH (ADULT) 5.1GM	250	RC	A9270	CPT				Both			17.97	8.09	0.01	16.17	0.01							Fee Schedule		13.3							Fee Schedule																													16.17							Fee Schedule																																															
ORAJEL MAXIMUM STRENGTH (ADULT) 7GM	250	RC	A9270	CPT				Both			14.7	6.62	0.01	13.23	0.01							Fee Schedule		10.88							Fee Schedule																													13.23							Fee Schedule																																															
ORAL RAE CUFFED 5.0 MALLINKR 76251	272	RC						Both			34	15.3	15.3	30.6	22.1							Fee Schedule		25.16							Fee Schedule																													30.6							Fee Schedule																																															
ORAL RAE CUFFED 5.5 MALLINKR 76255	272	RC						Both			24	10.8	10.8	21.6	15.6							Fee Schedule		17.76							Fee Schedule																													21.6							Fee Schedule																																															
ORAL RAE CUFFED 6.0 MALLINKR 76260	272	RC						Both			24	10.8	10.8	21.6	15.6							Fee Schedule		17.76							Fee Schedule																													21.6							Fee Schedule																																															
ORAL RAE CUFFED 7.0 MALLINKR 76270	272	RC						Both			24	10.8	10.8	21.6	15.6							Fee Schedule		17.76							Fee Schedule																													21.6							Fee Schedule																																															
ORAL RAE CUFFED 8.0 MALLINKR 76280	272	RC						Both			24	10.8	10.8	21.6	15.6							Fee Schedule		17.76							Fee Schedule																													21.6							Fee Schedule																																															
ORAL SUCTION SWAB DISP. #6513	270	RC						Both			3.09	1.39	1.39	2.78	2.01							Fee Schedule		2.29							Fee Schedule																													2.78							Fee Schedule																																															
ORAL SYRINGE 5ML #16035W (ER)	270	RC						Both			1	0.45	0.45	0.9	0.65							Fee Schedule		0.74							Fee Schedule																													0.9							Fee Schedule																																															
ORBIT FULL RADIUS 4.5 7204928 SMITHNEPHE	272	RC						Both			292.95	131.83	131.83	263.66	190.42							Fee Schedule		216.78							Fee Schedule																													263.66							Fee Schedule																																															
ORBIT INCISOR 4.5 7204700 SMITH NEPHEW	272	RC						Both			253.05	113.87	113.87	227.75	164.48							Fee Schedule		187.26							Fee Schedule																													227.75							Fee Schedule																																															
ORBITS BILAT	320	RC	70200	CPT				Both			315	141.75	22.35	318	22.88							Fee Schedule		27.14							Fee Schedule											22.35							Fee Schedule											283.5							Fee Schedule																				318							Per Diem																				
ORCAPOD AIR/WATER W/ CONN. #SUV-629-50	272	RC						Both			28	12.6	12.6	25.2	18.2							Fee Schedule		20.72							Fee Schedule																													25.2							Fee Schedule																																															
ORENCIA INTRAVENOUS PWD FOR SOLN 250MG	636	RC	J0129	CPT				Both			5580	2511	44.72	5022		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	44.72							Fee Schedule		46.11							Fee Schedule																				5022							Fee Schedule																																															
"ORGANIC ACIDS, COMP, QUAN, UR 35819"	301	RC	83918	CPT				Both			771	346.95	16.99	693.9	16.99							Fee Schedule		23.6							Fee Schedule		24.31							Fee Schedule		23.6							Fee Schedule											693.9							Fee Schedule																				23.6							Fee Schedule																				
CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC					547	DRG		Inpatient			22990.59	10345.77	10345.77	10345.77							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period							0		No services provided during 15 month lookback period				5698.7	5698.7	5698.7	1 through 10									0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period	
ORGANO PHOS PESTI SERUM (30499)4M	301	RC	82542	CPT				Both			207.9	93.56	17.34	187.11	17.34							Fee Schedule		24.09							Fee Schedule		24.81							Fee Schedule		24.09							Fee Schedule		44.77							Fee Schedule		187.11							Fee Schedule		51.48							Fee Schedule		41.64							Fee Schedule		24.09							Fee Schedule		51.48							Fee Schedule		41.64							Fee Schedule		
ORGANO PHOSP PESTI URINE 6415   4ML	301	RC	82542	CPT				Both			192.15	86.47	17.34	172.94	17.34							Fee Schedule		24.09							Fee Schedule		24.81							Fee Schedule		24.09							Fee Schedule		23.6							Fee Schedule		172.94							Fee Schedule		27.14							Fee Schedule		21.95							Fee Schedule		24.09							Fee Schedule		27.14							Fee Schedule		21.95							Fee Schedule		
ORGANOGENESIS PURAPLY 2X4 #515-016	278	RC	Q4196	CPT				Both			338	152.1	130.95	304.2		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	250.12							Fee Schedule		130.95							Fee Schedule																				304.2							Fee Schedule																																															
ORGANOGENESIS PURAPLY 3X4 #515-065	278	RC	Q4196	CPT				Both			313	140.85	22.4	281.7		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	231.62							Fee Schedule		130.95							Fee Schedule											24.09							Fee Schedule		281.7							Fee Schedule		27.7							Fee Schedule		22.4							Fee Schedule											27.7							Fee Schedule		22.4							Fee Schedule		
ORPHENADRINE 100 MG TABLET UD	250	RC	A9270	CPT				Both			7.25	3.26	0.01	27.7	0.01							Fee Schedule		5.37							Fee Schedule																				24.09							Fee Schedule		6.53							Fee Schedule		27.7							Fee Schedule		22.4							Fee Schedule											27.7							Fee Schedule		22.4							Fee Schedule		
ORPHENADRINE 60 MG/2ML  (NORFLEX)  INJ	636	RC	J2360	CPT				Both			70.35	31.66	3.06	146.21		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	52.06							Fee Schedule		8.01							Fee Schedule		3.06							Fee Schedule		127.14							Fee Schedule		63.32							Fee Schedule		146.21							Fee Schedule		118.24							Fee Schedule											146.21							Fee Schedule		118.24							Fee Schedule		
ORTHASORB PIN	278	RC						Both			269.85	121.43	118.24	242.87		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	199.69							Fee Schedule																				127.14							Fee Schedule		242.87							Fee Schedule		146.21							Fee Schedule		118.24							Fee Schedule											146.21							Fee Schedule		118.24							Fee Schedule		
ORTHO PACK DYNJP8330 (MEDLINE)	270	RC						Both			48	21.6	21.6	43.2	31.2							Fee Schedule		35.52							Fee Schedule																													43.2							Fee Schedule																																															
ORTHOGLASS 2  #OG-2L2	271	RC	A4590	CPT				Both			8.4	3.78	3.78	24.09	20.24							Fee Schedule		6.22							Fee Schedule											24.09							Fee Schedule		7.78							Fee Schedule		7.56							Fee Schedule		8.94							Fee Schedule		7.23							Fee Schedule											8.94							Fee Schedule		7.23							Fee Schedule		
ORTHOGLASS 3  #OG-3L2	271	RC	A4590	CPT				Both			9	4.05	4.05	24.09	20.24							Fee Schedule		6.66							Fee Schedule											24.09							Fee Schedule											8.1							Fee Schedule																																															
ORTHOGLASS 4  #OG-4L2	271	RC	A4590	CPT				Both			11	4.95	4.95	24.09	20.24							Fee Schedule		8.14							Fee Schedule											24.09							Fee Schedule											9.9							Fee Schedule																																															
ORTHOGLASS 5  #OG-5L2	271	RC	A4590	CPT				Both			15	6.75	6.75	24.09	20.24							Fee Schedule		11.1							Fee Schedule											24.09							Fee Schedule											13.5							Fee Schedule																																															
ORTHOPEDIC SUCTION SYSTEM 0800-01S	272	RC						Both			72.45	32.6	32.6	65.21	47.09							Fee Schedule		53.61							Fee Schedule																													65.21							Fee Schedule																																															
ORTHO-VISC 15 MG/ML-2 ML SYRINGE	636	RC	J7324	CPT				Both			1640.1	738.05	109.1	1476.09		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	109.1							Fee Schedule		114.6							Fee Schedule																				1476.09							Fee Schedule																																															
OSCAL D 250 MG TABLET	250	RC	A9270	CPT				Both			5.25	2.36	0.01	4.73	0.01							Fee Schedule		3.89							Fee Schedule																													4.73							Fee Schedule																																															
OSCAL:500MG TABS	250	RC	A9270	CPT				Both			1.58	0.71	0.01	1.42	0.01							Fee Schedule		1.17							Fee Schedule																													1.42							Fee Schedule																																															
OSCILLATING BLADE HALL SURG. #5071-123	272	RC						Both			210	94.5	94.5	189	136.5							Fee Schedule		155.4							Fee Schedule																				111.26							Fee Schedule		189							Fee Schedule		127.95							Fee Schedule		103.47							Fee Schedule											127.95							Fee Schedule		103.47							Fee Schedule		
OSCILLATING BLADE HALL SURGICAL	272	RC						Both			277.2	124.74	124.74	249.48	180.18							Fee Schedule		205.13							Fee Schedule																													249.48							Fee Schedule																																															
OSELTAMIVIR (TAMIFLU) 30 MG  CAPSULE UD	250	RC	A9270	CPT				Both			50.16	22.57	0.01	45.14	0.01							Fee Schedule		37.12							Fee Schedule																													45.14							Fee Schedule																																															
OSELTAMIVIR (TAMIFLU) 75 MG  CAPSULE UD	250	RC	A9270	CPT				Both			18.9	8.51	0.01	17.01	0.01							Fee Schedule		13.99							Fee Schedule																													17.01							Fee Schedule																																															
OSELTAMIVIR (TAMIFLU) PWD SUSP 6MG/1ML	250	RC	A9270	CPT				Both			493.5	222.08	0.01	444.15	0.01							Fee Schedule		365.19							Fee Schedule																													444.15							Fee Schedule																																															
OSMOLALITY SERUM 677  2ML RM TM	301	RC	83930	CPT				Both			42	18.9	5.88	37.8	5.88							Fee Schedule		7.35							Fee Schedule		6.81							Fee Schedule		6.61							Fee Schedule											37.8							Fee Schedule																				6.61							Fee Schedule																				
OSMOLALITY URINE 678	301	RC	83935	CPT				Both			42	18.9	6.06	37.8	6.06							Fee Schedule		7.57							Fee Schedule		7.02							Fee Schedule		6.82							Fee Schedule											37.8							Fee Schedule																				6.82							Fee Schedule																				
OSMOLITE 1 CAL RTH 1000ML	250	RC						Both			18.9	8.51	8.51	17.01	12.29							Fee Schedule		13.99							Fee Schedule																													17.01							Fee Schedule																																															
OSMOLITE 1.2 CAL ORAL SOLUTION	636	RC	B4150	CPT				Both			18.6	8.37	0.84	16.74		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	13.76							Fee Schedule											0.84							Fee Schedule		6.61							Fee Schedule		16.74							Fee Schedule		7.6							Fee Schedule		6.15							Fee Schedule											7.6							Fee Schedule		6.15							Fee Schedule		
OSMOLITE READY TO HANG:1000 ML	250	RC						Both			34.65	15.59	6.34	31.19	22.52							Fee Schedule		25.64							Fee Schedule																				6.82							Fee Schedule		31.19							Fee Schedule		7.84							Fee Schedule		6.34							Fee Schedule											7.84							Fee Schedule		6.34							Fee Schedule		
OSMOPREP 1.5 GM TABLET	250	RC	A9270	CPT				Both			8.58	3.86	0.01	7.72	0.01							Fee Schedule		6.35							Fee Schedule																													7.72							Fee Schedule																																															
OSTEOCHONDRAL ALLO GRAFT	278	RC	C1762	CPT				Both			1601.25	720.56	720.56	1441.13		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1184.93							Fee Schedule																													1441.13							Fee Schedule																																															
SEPTIC ARTHRITIS WITH MCC					548	DRG		Inpatient			91386.78	41124.05	41124.05	41124.05							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period	
MEDICAL BACK PROBLEMS WITHOUT MCC					552	DRG		Inpatient			18786.73	8454.03	8454.03	8454.03							0		No services performed during 15 month lookback period. 				1010.5	1010.5	1010.5	1 through 10									0		No services performed during 15 month lookback period							0		No services provided during 15 month lookback period				5354.65	5354.65	5354.65	1 through 10									0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period	
OSTEONICS T2 HUMERAL NAIL 1830-0921S	278	RC						Both			4364.85	1964.18	1964.18	3928.37		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	3229.99							Fee Schedule																													3928.37							Fee Schedule																																															
OSTEOSET STANDARD 8400-0211	272	RC						Both			2677.5	1204.88	1204.88	2409.75	1740.38							Fee Schedule		1981.35							Fee Schedule																													2409.75							Fee Schedule																																															
OSTEOSET STANDARD 8400-0511	272	RC						Both			3559.5	1601.78	1601.78	3203.55	2313.68							Fee Schedule		2634.03							Fee Schedule																													3203.55							Fee Schedule																																															
OSTOMY FLANG EACH	271	RC						Both			9.45	4.25	4.25	8.51	6.14							Fee Schedule		6.99							Fee Schedule																													8.51							Fee Schedule																																															
OT EVAL HIGH COMPLEX 60 MIN	434	RC	97167	CPT				Both			315	141.75	64.77	318	200							Per Diem		233.1							Fee Schedule											64.77							Fee Schedule											283.5							Fee Schedule																				318							Per Diem																				
OT EVAL LOW COMPLEX 30 MIN	434	RC	97165	CPT				Both			315	141.75	64.77	318	200							Per Diem		233.1							Fee Schedule											64.77							Fee Schedule											283.5							Fee Schedule																				318							Per Diem																				
OT EVAL MOD COMPLEX 45 MIN	434	RC	97166	CPT				Both			315	141.75	64.77	318	200							Per Diem		233.1							Fee Schedule											64.77							Fee Schedule											283.5							Fee Schedule																				318							Per Diem																				
OT REEVAL EST PLAN CARE	424	RC	97168	CPT				Both			315	141.75	42.73	318	200							Per Diem		233.1							Fee Schedule											42.73							Fee Schedule											283.5							Fee Schedule																				318							Per Diem																				
OT WORK CONDITIONING	431	RC	97545	CPT				Both			488.25	219.71	200	439.43	200							Per Diem		361.31							Fee Schedule																													439.43							Fee Schedule																				318							Per Diem																				
OTA WORK CONDITIONI	431	RC	97545	CPT				Both			488.25	219.71	200	439.43	200							Per Diem		361.31							Fee Schedule																													439.43							Fee Schedule																				318							Per Diem																				
OTA WORK HARDENING EA ADDL	430	RC	97546	CPT				Both			194.25	87.41	87.41	318	200							Per Diem		143.75							Fee Schedule																													174.83							Fee Schedule																				318							Per Diem																				
BONE DISEASES AND ARTHROPATHIES WITHOUT MCC					554	DRG		Inpatient			17042.95	7669.33	7669.33	7669.33							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period	
"TENDONITIS, MYOSITIS AND BURSITIS WITH MCC"					557	DRG		Inpatient			20394.62	9177.58	9177.58	9177.58							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period	
"TENDONITIS, MYOSITIS AND BURSITIS WITHOUT MCC"					558	DRG		Inpatient			33572.77	15107.75	15107.75	15107.75							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period							0		No services provided during 15 month lookback period				2318.03	2318.03	2318.03	1 through 10									0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period	
"FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP,"					563	DRG		Inpatient			19555.4	8799.93	8799.93	8799.93							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period	
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES					565	DRG		Inpatient			20938.33	9422.25	9422.25	9422.25							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period	
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES					566	DRG		Inpatient			10159.8	4571.91	4571.91	4571.91							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period				2753.22	2753.22	2753.22	1 through 10									0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period	
SKIN DEBRIDEMENT WITH MCC					570	DRG		Inpatient			45025.82	20261.62	20261.62	20261.62							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period	
SKIN DEBRIDEMENT WITH CC					571	DRG		Inpatient			35116.84	15802.58	15802.58	15802.58							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period	
SKIN DEBRIDEMENT WITHOUT CC/MCC					572	DRG		Inpatient			26388.34	11874.75	11874.75	11874.75							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period	
"OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITH M"					579	DRG		Inpatient			29050.6	13072.77	13072.77	13072.77							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period	
"OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITH C"					580	DRG		Inpatient			42247.76	19011.49	19011.49	19011.49							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period	
"OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITHOU"					581	DRG		Inpatient			31795.18	14307.83	14307.83	14307.83							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period	
MASTECTOMY FOR MALIGNANCY WITHOUT CC/MCC					583	DRG		Inpatient			23534.13	10590.36	10590.36	10590.36							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period				4440.38	4440.38	4440.38	1 through 10									0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period	
SKIN ULCERS WITH CC					593	DRG		Inpatient			34991.46	15746.16	15746.16	15746.16							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period				3495.55	3495.55	3495.55	1 through 10									0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period	
MAJOR SKIN DISORDERS WITHOUT MCC					596	DRG		Inpatient			10830.55	4873.75	4873.75	4873.75							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period	
MALIGNANT BREAST DISORDERS WITH MCC					597	DRG		Inpatient			29767.34	13395.3	13395.3	13395.3							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period	
CELLULITIS WITH MCC					602	DRG		Inpatient			32067.07	14430.18	14430.18	14430.18							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period. 				9146.24	9146.24	9146.24	1 through 10									0		No services provided during 15 month lookback period				9117.24	9117.24	9117.24	1 through 10						10647.91	10647.91	10647.91	1 through 10									0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback				10310.47	10310.47	10310.47	1 through 10									0		No services provided during 15 month lookback period	
CELLULITIS WITHOUT MCC					603	DRG		Inpatient			24435.37	10995.92	10995.92	10995.92							0		No services performed during 15 month lookback period. 				8962.12	2668.68	24365.07	14						7186.06	7186.06	7186.06	1 through 10						1580.13	1580.13	1580.13	1 through 10						6062.56	5038.53	7482.07	1 through 10						1280.65	1280.65	1280.65	1 through 10									0		No services provided during 15 month lookback period				3388.48	3388.48	3388.48	1 through 10									0		No services provided during 15 month lookback				7268.25	7268.25	7268.25	1 through 10						1521.06	1521.06	1521.06	1 through 10			
"TRAUMA TO THE SKIN, SUBCUTANEOUS TISSUE AND BREAST WITHOUT M"					605	DRG		Inpatient			26850.2	12082.59	12082.59	12082.59							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period	
MINOR SKIN DISORDERS WITHOUT MCC					607	DRG		Inpatient			18859.17	8486.63	8486.63	8486.63							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period	
"AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND META"					616	DRG		Inpatient			54474.91	24513.71	24513.71	24513.71							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback							0		No services provided during 15 month lookback period				13975	13975	13975	1 through 10			
"AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND META"					617	DRG		Inpatient			38667.67	17400.45	17400.45	17400.45							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period. 				14236.34	14236.34	14236.34	1 through 10									0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period	
"SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE, NUTRITIONAL"					623	DRG		Inpatient			17436.74	7846.53	7846.53	7846.53							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback							0		No services provided during 15 month lookback period				7299.85	7299.85	7299.85	1 through 10			
"SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE, NUTRITIONAL"					624	DRG		Inpatient			22523.82	10135.72	10135.72	10135.72							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period	
"OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES W"					629	DRG		Inpatient			28453.55	12804.1	12804.1	12804.1							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period	
DIABETES WITH MCC					637	DRG		Inpatient			33847.61	15231.42	15231.42	15231.42							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period							0		No services provided during 15 month lookback period				10212.04	10212.04	10212.04	1 through 10									0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period				10874.46	10874.46	10874.46	1 through 10									0		No services provided during 15 month lookback				11345.71	11345.71	11345.71	1 through 10									0		No services provided during 15 month lookback period	
DIABETES WITH CC					638	DRG		Inpatient			23316.24	10492.31	10492.31	10492.31							0		No services performed during 15 month lookback period. 				2982.63	2982.63	2982.63	1 through 10						7248.47	7248.47	7248.47	1 through 10						3003.56	3003.56	3003.56	1 through 10						3086.1	3086.1	3086.1	1 through 10						11741.85	11741.85	11741.85	1 through 10									0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback				7350.08	7350.08	7350.08	1 through 10						3639.39	3639.39	3639.39	1 through 10			
DIABETES WITHOUT CC/MCC					639	DRG		Inpatient			16799.15	7559.62	7559.62	7559.62							0		No services performed during 15 month lookback period. 				3177.27	1409.28	5811.62	1 through 10									0		No services performed during 15 month lookback period							0		No services provided during 15 month lookback period				3374.12	3374.12	3374.12	1 through 10									0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback							0		No services provided during 15 month lookback period				2693	2693	2693	1 through 10			
"MISCELLANEOUS DISORDERS OF NUTRITION, METABOLISM, FLUIDS AND"					640	DRG		Inpatient			27968.61	12585.87	12585.87	12585.87							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period							0		No services provided during 15 month lookback period				6728.81	6728.81	6728.81	1 through 10									0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback				11502.48	11502.48	11502.48	1 through 10									0		No services provided during 15 month lookback period	
"MISCELLANEOUS DISORDERS OF NUTRITION, METABOLISM, FLUIDS AND"					641	DRG		Inpatient			22041.35	9918.61	9918.61	9918.61							0		No services performed during 15 month lookback period. 				2277.87	1456.34	4045.92	1 through 10									0		No services performed during 15 month lookback period							0		No services provided during 15 month lookback period				2687.91	2687.91	2687.91	1 through 10									0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period				2586.55	2586.55	2586.55	1 through 10									0		No services provided during 15 month lookback				7096.51	7096.51	7096.51	1 through 10						3304.34	3304.34	3304.34	1 through 10			
ENDOCRINE DISORDERS WITH CC					644	DRG		Inpatient			26876.49	12094.42	12094.42	12094.42							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period	
MAJOR BLADDER PROCEDURES WITH CC					654	DRG		Inpatient			67472.25	30362.51	30362.51	30362.51							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period	
KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITH CC					657	DRG		Inpatient			48883.01	21997.35	21997.35	21997.35							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period	
KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITHOUT CC/MCC					658	DRG		Inpatient			52352.93	23558.82	23558.82	23558.82							0		No services performed during 15 month lookback period. 				4120.78	4120.78	4120.78	1 through 10									0		No services performed during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period	
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH MCC					659	DRG		Inpatient			49640.48	22338.22	22338.22	22338.22							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period	
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH CC					660	DRG		Inpatient			26392.23	11876.5	11876.5	11876.5							0		No services performed during 15 month lookback period. 				4405.09	4405.09	4405.09	1 through 10									0		No services performed during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period	
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITHOUT CC/MCC					661	DRG		Inpatient			37427.39	16842.33	16842.33	16842.33							0		No services performed during 15 month lookback period. 				5086.29	5086.29	5086.29	1 through 10									0		No services performed during 15 month lookback period							0		No services provided during 15 month lookback period				6225.53	6225.53	6225.53	1 through 10									0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period				4891.31	4891.31	4891.31	1 through 10									0		No services provided during 15 month lookback							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period	
PROSTATECTOMY WITH MCC					665	DRG		Inpatient			114456.1	51505.25	51505.25	51505.25							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period	
OTRIVIN PEDIATRIC NOSE DROPS	250	RC	A9270	CPT				Both			21.07	9.48	0.01	18.96	0.01							Fee Schedule		15.59							Fee Schedule																													18.96							Fee Schedule																																															
OVERTUBE #00711148  ( US ENDOSCOPY )	272	RC						Both			677.25	304.76	304.76	609.53	440.21							Fee Schedule		501.17							Fee Schedule																													609.53							Fee Schedule																																															
OWENS DRESSING (SENECA MEDICAL)	272	RC						Both			11.55	5.2	5.2	10.4	7.51							Fee Schedule		8.55							Fee Schedule																													10.4							Fee Schedule																																															
OXACILLIN 2 GM INJECTION	636	RC	J2700	CPT				Both			15.75	7.09	0.79	14.18		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	11.66							Fee Schedule		0.79							Fee Schedule		1.83							Fee Schedule											14.18							Fee Schedule																																															
OXACILLIN 250 MG/5ML ORAL SUSP	250	RC	A9270	CPT				Both			45.93	20.67	0.01	41.34	0.01							Fee Schedule		33.99							Fee Schedule																													41.34							Fee Schedule																																															
OXACILLIN 2GMS/NS 100 ML IVPB	636	RC	S0040	CPT				Both			75.85	34.13	34.13	68.27		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	56.13							Fee Schedule																													68.27							Fee Schedule																																															
OXALATE 682 URINE 24HR	301	RC	83945	CPT				Both			59.85	26.93	0.71	53.87	11.44							Fee Schedule		14.45							Fee Schedule		14.88							Fee Schedule		14.45							Fee Schedule		0.76							Fee Schedule		53.87							Fee Schedule		0.88							Fee Schedule		0.71							Fee Schedule		14.45							Fee Schedule		0.88							Fee Schedule		0.71							Fee Schedule		
OXAZEPAM 10 MG (SERAX) CAPSULE	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
OXAZEPAM 15 MG CAPSULE UD	250	RC	A9270	CPT				Both			4.2	1.89	0.01	3.78	0.01							Fee Schedule		3.11							Fee Schedule																													3.78							Fee Schedule																																															
OXCARBAZEPINE 36637 SERUM TRILEPTAL	301	RC	82542	CPT				Both			159.6	71.82	13.44	143.64	17.34							Fee Schedule		24.09							Fee Schedule		24.81							Fee Schedule		24.09							Fee Schedule		14.45							Fee Schedule		143.64							Fee Schedule		16.62							Fee Schedule		13.44							Fee Schedule		24.09							Fee Schedule		16.62							Fee Schedule		13.44							Fee Schedule		
OXEPA TUBE FEEDING 1000 ML RTH	250	RC	B4154	CPT				Both			24.15	10.87	0.36	21.74	0.36							Fee Schedule		17.87							Fee Schedule											2.21							Fee Schedule											21.74							Fee Schedule																																															
OXIMETRY CONT.	460	RC	94762	CPT				Both			283.5	127.58	34.63	318	200							Per Diem		209.79							Fee Schedule											34.63							Fee Schedule											255.15							Fee Schedule																				318							Per Diem																				
OXIMETRY SINGLE	460	RC	94760	CPT				Both			283.5	127.58	7.83	318	200							Per Diem		209.79							Fee Schedule											7.83							Fee Schedule		24.09							Fee Schedule		255.15							Fee Schedule		27.7							Fee Schedule		22.4							Fee Schedule		318							Per Diem		27.7							Fee Schedule		22.4							Fee Schedule		
OXIMETRY/CONT	460	RC	94762	CPT				Both			283.5	127.58	34.63	318	200							Per Diem		209.79							Fee Schedule											34.63							Fee Schedule											255.15							Fee Schedule																				318							Per Diem																				
OXY IR 5 MG CAPS  (OXYCODONE)	250	RC	A9270	CPT				Both			7.35	3.31	0.01	6.62	0.01							Fee Schedule		5.44							Fee Schedule																													6.62							Fee Schedule																																															
OXYBUTYNIN 5MG (DITROPAN) TABLET	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
OXYBUTYNIN ER 5MG TABLET	250	RC	A9270	CPT				Both			9.45	4.25	0.01	8.51	0.01							Fee Schedule		6.99							Fee Schedule																													8.51							Fee Schedule																																															
OXYBUTYNIN XL 5 MG TABLET UD	250	RC	A9270	CPT				Both			10.76	4.84	0.01	9.68	0.01							Fee Schedule		7.96							Fee Schedule																													9.68							Fee Schedule																																															
OXYCODONE & METABOLITE 17125 URI RT	300	RC	80307	CPT				Both			115.5	51.98	51.72	103.95	51.72							Fee Schedule		64.65							Fee Schedule		64							Fee Schedule		62.14							Fee Schedule											103.95							Fee Schedule																				62.14							Fee Schedule																				
OXYCODONE & METABOLITE 17125 URI RT	301	RC	G0480	CPT				Both			115.5	51.98	51.98	117.86	82.39							Fee Schedule		114.43							Fee Schedule		117.86							Fee Schedule		114.43							Fee Schedule											103.95							Fee Schedule																																															
OXYCODONE & METABOLITE 18885 5ML SER RT	301	RC	G0480	CPT				Both			115.5	51.98	51.98	117.86	82.39							Fee Schedule		114.43							Fee Schedule		117.86							Fee Schedule		114.43							Fee Schedule											103.95							Fee Schedule																																															
oxyCODONE 5 MG (IMMEDIATE RELEASE) TAB	250	RC	A9270	CPT				Both			6.3	2.84	0.01	71.46	0.01							Fee Schedule		4.66							Fee Schedule																				62.14							Fee Schedule		5.67							Fee Schedule		71.46							Fee Schedule		57.79							Fee Schedule											71.46							Fee Schedule		57.79							Fee Schedule		
OXYCODONE 5MG/5ML ORAL SOLUTION-UD	250	RC	A9270	CPT				Both			15.78	7.1	0.01	131.59	0.01							Fee Schedule		11.68							Fee Schedule																				114.43							Fee Schedule		14.2							Fee Schedule		131.59							Fee Schedule		106.42							Fee Schedule											131.59							Fee Schedule		106.42							Fee Schedule		
OXYCODONE/ACETAMINOPHEN  7.5MG/325MG TAB	250	RC	A9270	CPT				Both			8.4	3.78	0.01	131.59	0.01							Fee Schedule		6.22							Fee Schedule																				114.43							Fee Schedule		7.56							Fee Schedule		131.59							Fee Schedule		106.42							Fee Schedule											131.59							Fee Schedule		106.42							Fee Schedule		
OXYCODONE/ACETAMINOPHEN 10MG/325MG TAB	250	RC	A9270	CPT				Both			11.55	5.2	0.01	10.4	0.01							Fee Schedule		8.55							Fee Schedule																													10.4							Fee Schedule																																															
OXYCODONE/ACETAMINOPHEN 5/325MG TAB	250	RC	A9270	CPT				Both			7.35	3.31	0.01	6.62	0.01							Fee Schedule		5.44							Fee Schedule																													6.62							Fee Schedule																																															
oxyCONTIN 10 MG EXTENDED RELEASE TAB	250	RC	A9270	CPT				Both			7.35	3.31	0.01	6.62	0.01							Fee Schedule		5.44							Fee Schedule																													6.62							Fee Schedule																																															
oxyCONTIN 40 MG EXTENDED RELEASE TAB	250	RC	A9270	CPT				Both			18.9	8.51	0.01	17.01	0.01							Fee Schedule		13.99							Fee Schedule																													17.01							Fee Schedule																																															
OXYCONTIN 80 MG TABLET UD	250	RC	A9270	CPT				Both			31.5	14.18	0.01	28.35	0.01							Fee Schedule		23.31							Fee Schedule																													28.35							Fee Schedule																																															
OXYGEN DILUTOR 384-26	271	RC	A4649	CPT				Both			8	3.6	3.6	7.2	5.2							Fee Schedule		5.92							Fee Schedule																													7.2							Fee Schedule																																															
OXYGEN GAS FOR PFT #536052-001	270	RC						Both			677.25	304.76	304.76	609.53	440.21							Fee Schedule		501.17							Fee Schedule																													609.53							Fee Schedule																																															
OXYGEN MASK HUDSON HUDRHO41U  MEDLINE	271	RC						Both			2	0.9	0.9	1.8	1.3							Fee Schedule		1.48							Fee Schedule																													1.8							Fee Schedule																																															
OXYGEN SENSOR LNCS INF 2328	272	RC						Both			17	7.65	7.65	15.3	11.05							Fee Schedule		12.58							Fee Schedule																													15.3							Fee Schedule																																															
OXYGEN SENSOR OXI-P/I	270	RC						Both			39.9	17.96	17.96	35.91	25.94							Fee Schedule		29.53							Fee Schedule																													35.91							Fee Schedule																																															
OXYGEN TUBING 1115 HUDSON	272	RC	A4616	CPT				Both			1	0.45	0.06	0.9	0.06							Fee Schedule		0.74							Fee Schedule		0.08							Fee Schedule		0.07							Fee Schedule											0.9							Fee Schedule																																															
OXYKID AEROSOL MASK-PED OKN-1000	271	RC						Both			9.45	4.25	4.25	8.51	6.14							Fee Schedule		6.99							Fee Schedule																													8.51							Fee Schedule																																															
OXYPAP W/ GAUGE & TUBING DR BURTON 562	270	RC						Both			54	24.3	24.3	48.6	35.1							Fee Schedule		39.96							Fee Schedule																													48.6							Fee Schedule																																															
OXYPLUS MASK LG W/ 7' TUBING OP-1125-8	271	RC						Both			12.6	5.67	0.07	11.34	8.19							Fee Schedule		9.32							Fee Schedule																				0.08							Fee Schedule		11.34							Fee Schedule		0.09							Fee Schedule		0.07							Fee Schedule											0.09							Fee Schedule		0.07							Fee Schedule		
OXYTOCIN 10 UNITS/ML VIAL-1ML INJ.	636	RC	J2590	CPT				Both			14.7	6.62	1.58	13.23		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	10.88							Fee Schedule											1.58							Fee Schedule											13.23							Fee Schedule																																															
OXYTOCIN 10 UNITS/ML-10ML VIAL(PITOCIN)	636	RC	J2590	CPT				Both			807.3	363.29	1.58	726.57		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	597.4							Fee Schedule											1.58							Fee Schedule											726.57							Fee Schedule																																															
PACERONE 100 MG (AMIODARONE) TABLET	250	RC	A9270	CPT				Both			52.5	23.63	0.01	47.25	0.01							Fee Schedule		38.85							Fee Schedule																													47.25							Fee Schedule																																															
PACERONE 200 MG (AMIODARONE) TABLET	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
PACIFIER PHILIPS SOOTHIE  #96004-N	270	RC						Both			3.5	1.58	1.58	3.15	2.28							Fee Schedule		2.59							Fee Schedule																													3.15							Fee Schedule																																															
PACKING GAUZE SILVER DRESSING 46-PG12	272	RC						Both			24.15	10.87	10.87	21.74	15.7							Fee Schedule		17.87							Fee Schedule																													21.74							Fee Schedule																																															
PALM CUP #26-55-4060  (TRI-ANIM)	272	RC						Both			23.1	10.4	10.4	20.79	15.02							Fee Schedule		17.09							Fee Schedule																													20.79							Fee Schedule																																															
PAMIDRONATE 90 MG (AREDIA) IVPB	636	RC	J2430	CPT				Both			366.45	164.9	12.39	329.81		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	271.17							Fee Schedule		12.39							Fee Schedule		280.51							Fee Schedule											329.81							Fee Schedule																																															
PAMIDRONATE DISODIUM 30 MG VIAL	636	RC	J2430	CPT				Both			961.8	432.81	12.39	865.62		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	711.73							Fee Schedule		12.39							Fee Schedule		280.51							Fee Schedule											865.62							Fee Schedule																																															
PAMPERS INFANT I	271	RC						Both			1.58	0.71	0.71	1.42	1.03							Fee Schedule		1.17							Fee Schedule																													1.42							Fee Schedule																																															
PAMPERS NEWBORN (0-10LB) #30374	271	RC	A4520	CPT				Both			1.05	0.47	0.47	13.83	1							Fee Schedule		0.78							Fee Schedule																				12.03							Fee Schedule		0.95							Fee Schedule		13.83							Fee Schedule		11.18							Fee Schedule											13.83							Fee Schedule		11.18							Fee Schedule		
PAMPERS SIZE 1 (8-14LB) #06729	271	RC	A4520	CPT				Both			7	3.15	1	13.83	1							Fee Schedule		5.18							Fee Schedule																				12.03							Fee Schedule		6.3							Fee Schedule		13.83							Fee Schedule		11.18							Fee Schedule											13.83							Fee Schedule		11.18							Fee Schedule		
PAMPERS SIZE 2 (12-18LB) #06555	271	RC	A4520	CPT				Both			2.1	0.95	0.95	1.89	1							Fee Schedule		1.55							Fee Schedule																													1.89							Fee Schedule																																															
PAMPERS SIZE 3 (16-28LB) #82843	271	RC	A4520	CPT				Both			3	1.35	1	2.7	1							Fee Schedule		2.22							Fee Schedule																													2.7							Fee Schedule																																															
PAMPERS SIZE 4 (22-37LB) #74958	271	RC	A4520	CPT				Both			31	13.95	1	27.9	1							Fee Schedule		22.94							Fee Schedule																													27.9							Fee Schedule																																															
PAMPERS SIZE 5 (27LB+) #74959	271	RC	A4520	CPT				Both			3.15	1.42	1	2.84	1							Fee Schedule		2.33							Fee Schedule																													2.84							Fee Schedule																																															
PAMPERS SIZE 6 (35LB+) #3700074961	271	RC						Both			3.15	1.42	1.42	2.84	2.05							Fee Schedule		2.33							Fee Schedule																													2.84							Fee Schedule																																															
PANCREATIC POLYPEPTIDE 4789  EDTA	301	RC	83519	CPT				Both			281.4	126.63	13.25	253.26	13.25							Fee Schedule		18.4							Fee Schedule		18.95							Fee Schedule		18.4							Fee Schedule											253.26							Fee Schedule																				18.4							Fee Schedule																				
PANCRELIPASE (PANCREASE) CAPSULE	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
PANCURONIUM 10 MG/10 ML (1MG/ML) MDV	250	RC						Both			11.81	5.31	5.31	10.63	7.68							Fee Schedule		8.74							Fee Schedule																													10.63							Fee Schedule																																															
PANHEMATIN 313 MG VIAL	636	RC	J1640	CPT				Both			27331.5	12299.18	17.11	24598.35		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	35.31							Fee Schedule		36.37							Fee Schedule											18.4							Fee Schedule		24598.35							Fee Schedule		21.16							Fee Schedule		17.11							Fee Schedule											21.16							Fee Schedule		17.11							Fee Schedule		
PANHEMATIN IV PWD FOR SOLN 350MG	250	RC	J1640	CPT				Both			36052	16223.4	23.72	32446.8	23.72							Fee Schedule		35.31							Fee Schedule		36.37							Fee Schedule																				32446.8							Fee Schedule																																															
PANMIST DM LIQUID 5ML UD	250	RC	A9270	CPT				Both			4.2	1.89	0.01	3.78	0.01							Fee Schedule		3.11							Fee Schedule																													3.78							Fee Schedule																																															
PANMIST S LIQUID	250	RC	A9270	CPT				Both			4.2	1.89	0.01	40.61	0.01							Fee Schedule		3.11							Fee Schedule																				35.31							Fee Schedule		3.78							Fee Schedule		40.61							Fee Schedule		32.84							Fee Schedule											40.61							Fee Schedule		32.84							Fee Schedule		
PANTIES PER PACK	271	RC						Both			5.25	2.36	2.36	40.61	3.41							Fee Schedule		3.89							Fee Schedule																				35.31							Fee Schedule		4.73							Fee Schedule		40.61							Fee Schedule		32.84							Fee Schedule											40.61							Fee Schedule		32.84							Fee Schedule		
PAP SMEAR COLLECTION 60115-10/50	272	RC						Both			5	2.25	2.25	4.5	3.25							Fee Schedule		3.7							Fee Schedule																													4.5							Fee Schedule																																															
PAP SMEAR COLLECTION W/BRUSH 10115-10/50	272	RC						Both			5	2.25	2.25	4.5	3.25							Fee Schedule		3.7							Fee Schedule																													4.5							Fee Schedule																																															
PAPA SIL 1.52 W/TAB NOTCH (MEDTRONIC USA	272	RC						Both			37.8	17.01	17.01	34.02	24.57							Fee Schedule		27.97							Fee Schedule																													34.02							Fee Schedule																																															
PARA CERVICAL TRAY	272	RC						Both			40.95	18.43	18.43	36.86	26.62							Fee Schedule		30.3							Fee Schedule																													36.86							Fee Schedule																																															
PARAFON FORTE TABLET	250	RC	A9270	CPT				Both			4.2	1.89	0.01	3.78	0.01							Fee Schedule		3.11							Fee Schedule																													3.78							Fee Schedule																																															
PARASITE IDENTIFICATION 3950	306	RC	87169	CPT				Both			55.65	25.04	3.79	50.09	3.79							Fee Schedule		4.75							Fee Schedule		4.44							Fee Schedule		4.31							Fee Schedule											50.09							Fee Schedule																				4.31							Fee Schedule																				
PARATHYROID HORM INTACT 35202	301	RC	83970	CPT				Both			225.75	101.59	36.69	203.18	36.69							Fee Schedule		45.86							Fee Schedule		42.52							Fee Schedule		41.28							Fee Schedule											203.18							Fee Schedule																				41.28							Fee Schedule																				
PARATHYROID HORM INTACT CALCIUM 8837	301	RC	83970	CPT				Both			225.75	101.59	36.69	203.18	36.69							Fee Schedule		45.86							Fee Schedule		42.52							Fee Schedule		41.28							Fee Schedule											203.18							Fee Schedule																				41.28							Fee Schedule																				
PARIETAL CELL AB 262 SERUM 1 ML	302	RC	86255	CPT				Both			140.7	63.32	4.01	126.63	10.71							Fee Schedule		13.39							Fee Schedule		12.41							Fee Schedule		12.05							Fee Schedule		4.31							Fee Schedule		126.63							Fee Schedule		4.96							Fee Schedule		4.01							Fee Schedule		12.05							Fee Schedule		4.96							Fee Schedule		4.01							Fee Schedule		
PARLODEL 5 MG TAB	250	RC	A9270	CPT				Both			13.34	6	0.01	47.47	0.01							Fee Schedule		9.87							Fee Schedule																				41.28							Fee Schedule		12.01							Fee Schedule		47.47							Fee Schedule		38.39							Fee Schedule											47.47							Fee Schedule		38.39							Fee Schedule		
PARoxetine 10MG (PAXIL) TABLET	250	RC	A9270	CPT				Both			8.4	3.78	0.01	47.47	0.01							Fee Schedule		6.22							Fee Schedule																				41.28							Fee Schedule		7.56							Fee Schedule		47.47							Fee Schedule		38.39							Fee Schedule											47.47							Fee Schedule		38.39							Fee Schedule		
PARoxetine 20MG (PAXIL) TABLET	250	RC	A9270	CPT				Both			6.3	2.84	0.01	13.86	0.01							Fee Schedule		4.66							Fee Schedule																				12.05							Fee Schedule		5.67							Fee Schedule		13.86							Fee Schedule		11.21							Fee Schedule											13.86							Fee Schedule		11.21							Fee Schedule		
PAROXETINE CR 12.5 MG TABLET UD	250	RC	A9270	CPT				Both			9.19	4.14	0.01	8.27	0.01							Fee Schedule		6.8							Fee Schedule																													8.27							Fee Schedule																																															
PARVOVIRUS B19 34296 PCR PPT TUBE	302	RC	87798	CPT				Both			189	85.05	31.2	170.1	31.2							Fee Schedule		38.99							Fee Schedule		36.14							Fee Schedule		35.09							Fee Schedule											170.1							Fee Schedule																				35.09							Fee Schedule																				
PARVOVIRUS B19 AB IGM 8948 SERUM	302	RC	86747	CPT				Both			84	37.8	13.36	75.6	13.36							Fee Schedule		16.7							Fee Schedule		15.48							Fee Schedule		15.03							Fee Schedule											75.6							Fee Schedule																				15.03							Fee Schedule																				
PARVOVIRUS B19 AB PANEL 8946 SERUM	302	RC	86747	CPT				Both			117.6	52.92	13.36	105.84	13.36							Fee Schedule		16.7							Fee Schedule		15.48							Fee Schedule		15.03							Fee Schedule											105.84							Fee Schedule																				15.03							Fee Schedule																				
PASSY MUIR SPEAKING VALVE PMV2000	270	RC	L8501	CPT				Both			318	143.1	32.63	286.2	74.04							Fee Schedule		235.32							Fee Schedule		184.8							Fee Schedule		110.41							Fee Schedule		35.09							Fee Schedule		286.2							Fee Schedule		40.35							Fee Schedule		32.63							Fee Schedule											40.35							Fee Schedule		32.63							Fee Schedule		
PATANOL 0.1%	250	RC	A9270	CPT				Both			296.1	133.25	0.01	266.49	0.01							Fee Schedule		219.11							Fee Schedule																				15.03							Fee Schedule		266.49							Fee Schedule		17.28							Fee Schedule		13.98							Fee Schedule											17.28							Fee Schedule		13.98							Fee Schedule		
PATHFINDER GUIDEWIRE 5159	272	RC	C1769	CPT				Both			528.15	237.67	13.98	475.34	154.26							Fee Schedule		390.83							Fee Schedule																				15.03							Fee Schedule		475.34							Fee Schedule		17.28							Fee Schedule		13.98							Fee Schedule											17.28							Fee Schedule		13.98							Fee Schedule		
PATHFINDER PLUS IRRIGATION SYSTEM  PA701	272	RC						Both			119	53.55	53.55	206.33	77.35							Fee Schedule		88.06							Fee Schedule																				179.42							Fee Schedule		107.1							Fee Schedule		206.33							Fee Schedule		166.86							Fee Schedule											206.33							Fee Schedule		166.86							Fee Schedule		
RENAL FAILURE WITH MCC					682	DRG		Inpatient			36443.23	16399.45	16399.45	16399.45							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period	
RENAL FAILURE WITH CC					683	DRG		Inpatient			23671.59	10652.22	10652.22	10652.22							0		No services performed during 15 month lookback period. 				4018.08	4018.08	4018.08	1 through 10									0		No services performed during 15 month lookback period				3599.28	3599.28	3599.28	1 through 10									0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period	
PATIENT DEMONSTRATION/OR EVAL	412	RC	94664	CPT				Both			283.5	127.58	16.28	286	175							Per Diem		209.79							Fee Schedule											16.28							Fee Schedule											255.15							Fee Schedule																				286							Case Rate																				
PATIENT LIFT SLING DISP. #MFA3000	271	RC	E0621	CPT				Both			78	35.1	35.1	102.76	54.54							Fee Schedule		57.72							Fee Schedule		102.76							Fee Schedule																				70.2							Fee Schedule																																															
PCA TUBING	272	RC						Both			39.9	17.96	17.96	35.91	25.94							Fee Schedule		29.53							Fee Schedule																													35.91							Fee Schedule																																															
PCE 333 MG TABLET	250	RC	A9270	CPT				Both			4.2	1.89	0.01	3.78	0.01							Fee Schedule		3.11							Fee Schedule																													3.78							Fee Schedule																																															
PCE 500 MG TABS	250	RC	A9270	CPT				Both			4.34	1.95	0.01	114.74	0.01							Fee Schedule		3.21							Fee Schedule																				99.77							Fee Schedule		3.91							Fee Schedule		114.74							Fee Schedule		92.79							Fee Schedule											114.74							Fee Schedule		92.79							Fee Schedule		
PCN 5 MIL.UNITS VIAL	250	RC						Both			12.33	5.55	5.55	11.1	8.01							Fee Schedule		9.12							Fee Schedule																													11.1							Fee Schedule																																															
PCP 34007 4ML SERUM RED	301	RC	80307	CPT				Both			159.6	71.82	51.72	143.64	51.72							Fee Schedule		64.65							Fee Schedule		64							Fee Schedule		62.14							Fee Schedule											143.64							Fee Schedule																				62.14							Fee Schedule																				
PD INITIAL	410	RC	94667	CPT				Both			283.5	127.58	17.94	286	175							Per Diem		209.79							Fee Schedule											17.94							Fee Schedule											255.15							Fee Schedule																				286							Case Rate																				
PDS #Z346H	272	RC						Both			13.65	6.14	6.14	12.29	8.87							Fee Schedule		10.1							Fee Schedule																													12.29							Fee Schedule																																															
PDS 2-0  Z333H	272	RC						Both			10	4.5	4.5	71.46	6.5							Fee Schedule		7.4							Fee Schedule																				62.14							Fee Schedule		9							Fee Schedule		71.46							Fee Schedule		57.79							Fee Schedule											71.46							Fee Schedule		57.79							Fee Schedule		
PDS 3 Z416H	272	RC						Both			9.45	4.25	4.25	8.51	6.14							Fee Schedule		6.99							Fee Schedule																													8.51							Fee Schedule																																															
PDS BLUNT TIP 0 ZB346	272	RC						Both			13	5.85	5.85	11.7	8.45							Fee Schedule		9.62							Fee Schedule																													11.7							Fee Schedule																																															
PDS II 2 Z304H	272	RC						Both			8	3.6	3.6	7.2	5.2							Fee Schedule		5.92							Fee Schedule																													7.2							Fee Schedule																																															
PDS II 2 Z317H	272	RC						Both			8	3.6	3.6	7.2	5.2							Fee Schedule		5.92							Fee Schedule																													7.2							Fee Schedule																																															
PDS II 2 Z339H	272	RC						Both			8	3.6	3.6	7.2	5.2							Fee Schedule		5.92							Fee Schedule																													7.2							Fee Schedule																																															
PDS II 2 Z880G	272	RC						Both			19	8.55	8.55	17.1	12.35							Fee Schedule		14.06							Fee Schedule																													17.1							Fee Schedule																																															
PDS II 5 Z493G	272	RC						Both			19	8.55	8.55	17.1	12.35							Fee Schedule		14.06							Fee Schedule																													17.1							Fee Schedule																																															
PEAK FLOW MEASUREMENT	460	RC	94010	CPT				Both			283.5	127.58	12.81	318	200							Per Diem		209.79							Fee Schedule											12.81							Fee Schedule											255.15							Fee Schedule																				318							Per Diem																				
PEAK FLOW METER 58-96510EA	271	RC	A4614	CPT				Both			27	12.15	12.15	34.91	21.41							Fee Schedule		19.98							Fee Schedule		34.91							Fee Schedule																				24.3							Fee Schedule																																															
PEANUT SPONGES 30-106 (DEROYAL)	272	RC						Both			1	0.45	0.45	0.9	0.65							Fee Schedule		0.74							Fee Schedule																													0.9							Fee Schedule																																															
PEAR BUR	272	RC						Both			202.65	91.19	91.19	182.39	131.72							Fee Schedule		149.96							Fee Schedule																													182.39							Fee Schedule																																															
PED. FOLEY CATH 6FR. 1.5CC	272	RC						Both			52	23.4	23.4	46.8	33.8							Fee Schedule		38.48							Fee Schedule																				33.89							Fee Schedule		46.8							Fee Schedule		38.97							Fee Schedule		31.52							Fee Schedule											38.97							Fee Schedule		31.52							Fee Schedule		
PEDIACARE DECONGESTANT/COUGH(INFANT)15ML	250	RC	A9270	CPT				Both			12.6	5.67	0.01	11.34	0.01							Fee Schedule		9.32							Fee Schedule																													11.34							Fee Schedule																																															
PEDIARIX VACCINE	636	RC	90723	CPT				Both			99.75	44.89	44.89	89.78		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	73.82							Fee Schedule																													89.78							Fee Schedule																																															
PEDIATRIC CATH KIT 5 FR. #DYND10820	272	RC						Both			6	2.7	2.7	5.4	3.9							Fee Schedule		4.44							Fee Schedule																													5.4							Fee Schedule																																															
PEDIATRIC CHEST TRO	272	RC						Both			44.1	19.85	19.85	39.69	28.67							Fee Schedule		32.63							Fee Schedule																													39.69							Fee Schedule																																															
PEDIATRIC FOLEY 8FR #DYND11553	271	RC						Both			14	6.3	6.3	12.6	9.1							Fee Schedule		10.36							Fee Schedule																													12.6							Fee Schedule																																															
PEDIATRIC FOLEY CATHETER 10FR #DYND11554	272	RC						Both			24	10.8	10.8	21.6	15.6							Fee Schedule		17.76							Fee Schedule																													21.6							Fee Schedule																																															
PEDIATRIC LAP DRAPE #DYNJP3007	272	RC						Both			13	5.85	5.85	11.7	8.45							Fee Schedule		9.62							Fee Schedule																													11.7							Fee Schedule																																															
PEDIATRIC WRIST SPLINT LEFT 12991102	274	RC	L3984	CPT				Both			37.8	17.01	17.01	472.19		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	27.97							Fee Schedule		472.19							Fee Schedule		329.1							Fee Schedule											34.02							Fee Schedule																																															
PEDIATRIC WRIST SPLINT RIGHT 12991202	274	RC	L3984	CPT				Both			37.8	17.01	17.01	472.19		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	27.97							Fee Schedule		472.19							Fee Schedule		329.1							Fee Schedule											34.02							Fee Schedule																																															
PEDIAZOLE 200 MG/5 ML SUSP-100ML	250	RC	A9270	CPT				Both			40.01	18	0.01	36.01	0.01							Fee Schedule		29.61							Fee Schedule																													36.01							Fee Schedule																																															
PEEP VALVES #AMB199003020 (MEDLINE)	270	RC						Both			14	6.3	6.3	527.21	9.1							Fee Schedule		10.36							Fee Schedule																				458.44							Fee Schedule		12.6							Fee Schedule		527.21							Fee Schedule		426.35							Fee Schedule											527.21							Fee Schedule		426.35							Fee Schedule		
PEG-24-BRT COOK	272	RC						Both			157.5	70.88	70.88	527.21	102.38							Fee Schedule		116.55							Fee Schedule																				458.44							Fee Schedule		141.75							Fee Schedule		527.21							Fee Schedule		426.35							Fee Schedule											527.21							Fee Schedule		426.35							Fee Schedule		
PEG-24-PUSH   WILSON COOK	272	RC						Both			405.3	182.39	182.39	364.77	263.45							Fee Schedule		299.92							Fee Schedule																													364.77							Fee Schedule																																															
PEGASUS DERMADAPT WOUND DSG. #WFXF400	278	RC	J3590	CPT				Both			5055.75	2275.09	2275.09	4550.18		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	3741.26							Fee Schedule																													4550.18							Fee Schedule																																															
PEG-INTRON 120 MCG/0.5ML INJECTION	636	RC	J9213	CPT				Both			1170.75	526.84	526.84	1053.68		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	866.36							Fee Schedule																													1053.68							Fee Schedule																																															
PELLO SHAVER BLADE 2.5MM ST 6290-208-025	272	RC						Both			735	330.75	330.75	661.5	477.75							Fee Schedule		543.9							Fee Schedule																													661.5							Fee Schedule																																															
PELLO SHAVER BLADE 2.5MM ST 6290-208-125	272	RC						Both			1176	529.2	529.2	1058.4	764.4							Fee Schedule		870.24							Fee Schedule																													1058.4							Fee Schedule																																															
PELLO SHAVER BLADE 3MM  6290-112-133	272	RC						Both			735	330.75	330.75	661.5	477.75							Fee Schedule		543.9							Fee Schedule																													661.5							Fee Schedule																																															
PELLO SHAVER BLADE 4MM  6290-112-140-12	272	RC						Both			735	330.75	330.75	661.5	477.75							Fee Schedule		543.9							Fee Schedule																													661.5							Fee Schedule																																															
PELLO SHAVER BLADE 4MM 6290-112-040-40	272	RC						Both			735	330.75	330.75	661.5	477.75							Fee Schedule		543.9							Fee Schedule																													661.5							Fee Schedule																																															
PELLO SHAVER BLADE 4MM 6290-112-040-60	272	RC						Both			735	330.75	330.75	661.5	477.75							Fee Schedule		543.9							Fee Schedule																													661.5							Fee Schedule																																															
PELLO SHAVER BLADE 4MM ST 6290-112-040	272	RC						Both			735	330.75	330.75	661.5	477.75							Fee Schedule		543.9							Fee Schedule																													661.5							Fee Schedule																																															
PELVIS	320	RC	72170	CPT				Both			315	141.75	15.04	318	18.8							Fee Schedule		21.95							Fee Schedule											15.04							Fee Schedule											283.5							Fee Schedule																				318							Per Diem																				
PELVIS AP FROG HIPS	320	RC	73521	CPT				Both			315	141.75	20.26	318	21.42							Fee Schedule		24.54							Fee Schedule											20.26							Fee Schedule											283.5							Fee Schedule																				318							Per Diem																				
PEN VEE K:250 MG TAB	250	RC	A9270	CPT				Both			1.58	0.71	0.01	1.42	0.01							Fee Schedule		1.17							Fee Schedule																													1.42							Fee Schedule																																															
PENICILLIN G 5 MUNITS/10ML INJECTION	636	RC	J2540	CPT				Both			17.85	8.03	0.66	16.07		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	13.21							Fee Schedule		0.66							Fee Schedule		1.06							Fee Schedule											16.07							Fee Schedule																																															
PENICILLIN G PROCAINE 600 UNITS/ML INJ	636	RC	J2510	CPT				Both			38.33	17.25	3.74	34.5		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	28.36							Fee Schedule											3.74							Fee Schedule											34.5							Fee Schedule																																															
PENICILLIN VK 250MG TABLET	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
PENICILLIN VK 250MG/5ML SUSP-100ML	250	RC	A9270	CPT				Both			9.45	4.25	0.01	8.51	0.01							Fee Schedule		6.99							Fee Schedule																				0.64							Fee Schedule		8.51							Fee Schedule		0.73							Fee Schedule		0.59							Fee Schedule											0.73							Fee Schedule		0.59							Fee Schedule		
PENICILLIN-G 20 MU	636	RC	J2540	CPT				Both			39.19	17.64	0.66	35.27		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	29							Fee Schedule		0.66							Fee Schedule		1.06							Fee Schedule											35.27							Fee Schedule																																															
PENICILLOYL G (c1) IgE 702	302	RC	86003	CPT				Both			19	8.55	4.64	17.1	4.64							Fee Schedule		5.8							Fee Schedule		5.38							Fee Schedule		5.22							Fee Schedule											17.1							Fee Schedule																				5.22							Fee Schedule																				
PENROSE DRAIN 1 INCH 30414-100	272	RC						Both			15	6.75	6.75	13.5	9.75							Fee Schedule		11.1							Fee Schedule																													13.5							Fee Schedule																																															
PENROSE DRAIN 1/2 INCH 30414-050	272	RC						Both			9	4.05	0.59	8.1	5.85							Fee Schedule		6.66							Fee Schedule																				0.64							Fee Schedule		8.1							Fee Schedule		0.73							Fee Schedule		0.59							Fee Schedule											0.73							Fee Schedule		0.59							Fee Schedule		
PENROSE DRAIN 1/4 INCH 30414-025	272	RC						Both			7	3.15	3.15	6.3	4.55							Fee Schedule		5.18							Fee Schedule																				5.22							Fee Schedule		6.3							Fee Schedule		6							Fee Schedule		4.85							Fee Schedule											6							Fee Schedule		4.85							Fee Schedule		
"PENTACEL VACCINE, DTaP, HIB, IPV"	636	RC	90698	CPT				Both			122.85	55.28	55.28	110.57		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	90.91							Fee Schedule																													110.57							Fee Schedule																																															
PENTAMIDINE 300 MG CAPSULE UD	636	RC	J2545	CPT				Both			334.69	150.61	75.19	301.22		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	247.67							Fee Schedule		75.19							Fee Schedule		136.2							Fee Schedule											301.22							Fee Schedule																																															
PENTASA 250 MG TABS	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
PENTOXIFYLLINE 400MG (TRENTAL) TABLET	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
PENUM DELIVERY MICROCATH PXSLIMLAN135T45	272	RC	C1887	CPT				Both			1770	796.5	43.86	1593	43.86							Fee Schedule		1309.8							Fee Schedule																				73							Fee Schedule		1593							Fee Schedule		83.95							Fee Schedule		67.89							Fee Schedule											83.95							Fee Schedule		67.89							Fee Schedule		
PENUM DELIVERY MICROCATH PXSLIMLAN160T45	272	RC	C1887	CPT				Both			1770	796.5	43.86	1593	43.86							Fee Schedule		1309.8							Fee Schedule																													1593							Fee Schedule																																															
PENUMBRA ASP. TORQ TIP CATH 8 CAT8TORQ85	272	RC	C1757	CPT				Both			9103.5	4096.58	16.33	8193.15	16.33							Fee Schedule		6736.59							Fee Schedule																													8193.15							Fee Schedule																																															
PENUMBRA ASPIRATION CATHETER 3 CAT3-A	272	RC	C1757	CPT				Both			3663.45	1648.55	16.33	3297.11	16.33							Fee Schedule		2710.95							Fee Schedule																													3297.11							Fee Schedule																																															
PENUMBRA ASPIRATION CATHETER 6 CAT6	272	RC	C1757	CPT				Both			5953.5	2679.08	16.33	5358.15	16.33							Fee Schedule		4405.59							Fee Schedule																													5358.15							Fee Schedule																																															
PENUMBRA ASPIRATION CATHETER D CATD-A	272	RC	C1757	CPT				Both			8788.5	3954.83	16.33	7909.65	16.33							Fee Schedule		6503.49							Fee Schedule																													7909.65							Fee Schedule																																															
PENUMBRA ASPIRATION TUBING IST3	272	RC	C1757	CPT				Both			1379.7	620.87	16.33	1241.73	16.33							Fee Schedule		1020.98							Fee Schedule																													1241.73							Fee Schedule																																															
PENUMBRA ENGINE CANISTER IAPS3	271	RC	A7000	CPT				Both			1095	492.75	6.56	985.5	6.56							Fee Schedule		810.3							Fee Schedule		10.82							Fee Schedule																				985.5							Fee Schedule																																															
PENUMBRA INDIGO SYSTEM IAPS2	271	RC						Both			1149.75	517.39	517.39	1034.78	747.34							Fee Schedule		850.82							Fee Schedule																													1034.78							Fee Schedule																																															
PENUMBRA INDIGO SYSTEM LITNG12HTORQ100	272	RC	C1757	CPT				Both			21073.5	9483.08	16.33	18966.15	16.33							Fee Schedule		15594.39							Fee Schedule																													18966.15							Fee Schedule																																															
PENUMBRA INDIGO SYSTEM LITNG12HTORQ115	272	RC	C1757	CPT				Both			21073.5	9483.08	9.77	18966.15	16.33							Fee Schedule		15594.39							Fee Schedule																				10.5							Fee Schedule		18966.15							Fee Schedule		12.08							Fee Schedule		9.77							Fee Schedule											12.08							Fee Schedule		9.77							Fee Schedule		
PENUMBRA INDIGO SYSTEM LITNGBT7TQ130	272	RC	C1757	CPT				Both			24060	10827	16.33	21654	16.33							Fee Schedule		17804.4							Fee Schedule																													21654							Fee Schedule																																															
PENUMBRA INDIGO SYSTEM LITNGFHT115BER	272	RC	C1757	CPT				Both			29310	13189.5	16.33	26379	16.33							Fee Schedule		21689.4							Fee Schedule																													26379							Fee Schedule																																															
PENUMBRA INDIGO SYSTEM LITNGFHT80BER	272	RC	C1757	CPT				Both			29310	13189.5	16.33	26379	16.33							Fee Schedule		21689.4							Fee Schedule																													26379							Fee Schedule																																															
PENUMBRA RUBY COIL #RBY2C0840	272	RC						Both			3840	1728	1728	3456	2496							Fee Schedule		2841.6							Fee Schedule																													3456							Fee Schedule																																															
PENUMBRA RUBY COIL #RBY4C0835	272	RC						Both			3840	1728	1728	3456	2496							Fee Schedule		2841.6							Fee Schedule																													3456							Fee Schedule																																															
PENUMBRA RUBY COIL #RBYPOD8	272	RC						Both			5070	2281.5	2281.5	4563	3295.5							Fee Schedule		3751.8							Fee Schedule																													4563							Fee Schedule																																															
PENUMBRA RUBY COIL DETACHMENT HANDLE RH1	272	RC						Both			714	321.3	321.3	642.6	464.1							Fee Schedule		528.36							Fee Schedule																													642.6							Fee Schedule																																															
PENUMBRA SEPARATOR 6 SEP6	272	RC	C1757	CPT				Both			3402	1530.9	16.33	3061.8	16.33							Fee Schedule		2517.48							Fee Schedule																													3061.8							Fee Schedule																																															
PENUMBRA SEPARATOR 8 SEP8-A	272	RC	C1757	CPT				Both			5922	2664.9	16.33	5329.8	16.33							Fee Schedule		4382.28							Fee Schedule																													5329.8							Fee Schedule																																															
PENUMBRA XTORQ TIP CATH 8 CAT8XTORQ115	272	RC	C1757	CPT				Both			9103.5	4096.58	16.33	8193.15	16.33							Fee Schedule		6736.59							Fee Schedule																													8193.15							Fee Schedule																																															
PEPCID 20MG/ML VIAL	250	RC						Both			10.57	4.76	4.76	9.51	6.87							Fee Schedule		7.82							Fee Schedule																													9.51							Fee Schedule																																															
PEPTAMEN JR 240ML CAN	250	RC	A9270	CPT				Both			23.1	10.4	0.01	20.79	0.01							Fee Schedule		17.09							Fee Schedule																													20.79							Fee Schedule																																															
PEPTO BISMOL (PINK BISMUTH) TABLET	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
PEPTO BISMOL SUSP-118ML	250	RC	A9270	CPT				Both			7.62	3.43	0.01	6.86	0.01							Fee Schedule		5.64							Fee Schedule																													6.86							Fee Schedule																																															
PERATIVE 240 ML	250	RC						Both			11.55	5.2	5.2	10.4	7.51							Fee Schedule		8.55							Fee Schedule																													10.4							Fee Schedule																																															
PERATIVE RTH 1000 ML	250	RC						Both			43.05	19.37	19.37	38.75	27.98							Fee Schedule		31.86							Fee Schedule																													38.75							Fee Schedule																																															
PERATIVE RTH 1500ML	250	RC						Both			22.05	9.92	9.92	19.85	14.33							Fee Schedule		16.32							Fee Schedule																													19.85							Fee Schedule																																															
PERCOCET 5MG TABS	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
PERCUFLEX NEPHROSTOMY CATH 10FX28 410112	272	RC	C1769	CPT				Both			255	114.75	114.75	229.5	154.26							Fee Schedule		188.7							Fee Schedule																													229.5							Fee Schedule																																															
PERCUFLEX NEPHROSTOMY CATH 10FX28 410205	272	RC	C1769	CPT				Both			296	133.2	133.2	266.4	154.26							Fee Schedule		219.04							Fee Schedule																													266.4							Fee Schedule																																															
PERCUFLEX+ URETERAL STENT #M0061752820	272	RC						Both			366	164.7	164.7	329.4	237.9							Fee Schedule		270.84							Fee Schedule																													329.4							Fee Schedule																																															
PERCUFLEX+ URETERAL STENT #M0061752830	272	RC						Both			366	164.7	164.7	329.4	237.9							Fee Schedule		270.84							Fee Schedule																													329.4							Fee Schedule																																															
PERCUFLEX+ URETERAL STENT #M0061752840	272	RC						Both			366	164.7	164.7	329.4	237.9							Fee Schedule		270.84							Fee Schedule																													329.4							Fee Schedule																																															
PERCUFLEX+ URETERAL STENT #M0061752850	272	RC						Both			366	164.7	164.7	329.4	237.9							Fee Schedule		270.84							Fee Schedule																													329.4							Fee Schedule																																															
PERCUSSION CUP MANUAL  PEDIATRIC	271	RC						Both			18.38	8.27	8.27	16.54	11.95							Fee Schedule		13.6							Fee Schedule																													16.54							Fee Schedule																																															
PERCUSSION CUPS MEDIUM 63MM   ( R.T. )	271	RC						Both			20	9	9	18	13							Fee Schedule		14.8							Fee Schedule																													18							Fee Schedule																																															
PERCUTANEOUS TRACH KIT BLUE RHINO G57716	272	RC	C1769	CPT				Both			1913	860.85	154.26	1721.7	154.26							Fee Schedule		1415.62							Fee Schedule																													1721.7							Fee Schedule																																															
PERDIEM LAXATIVE 250 GM.	250	RC	A9270	CPT				Both			38.33	17.25	0.01	34.5	0.01							Fee Schedule		28.36							Fee Schedule																													34.5							Fee Schedule																																															
PERFUSION CANNULA PER-3003S (MEDALLIANCE	272	RC						Both			13	5.85	5.85	11.7	8.45							Fee Schedule		9.62							Fee Schedule																													11.7							Fee Schedule																																															
PERI COLACE CAPSULE	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
PERI DOS SYRUP (OZ)	250	RC	A9270	CPT				Both			1.58	0.71	0.01	1.42	0.01							Fee Schedule		1.17							Fee Schedule																													1.42							Fee Schedule																																															
PERIACTIN SYRUP:OZ (CYPROCHEPTADINE)	250	RC	A9270	CPT				Both			1.77	0.8	0.01	1.59	0.01							Fee Schedule		1.31							Fee Schedule																													1.59							Fee Schedule																																															
PERIGEE PROLAPSE REPAIR # 720003-01( AMS	278	RC	C1781	CPT				Both			5273.1	2372.9	2372.9	4745.79		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	3902.09							Fee Schedule																													4745.79							Fee Schedule																																															
PERINEAL WASH 2	271	RC						Both			6.3	2.84	2.84	5.67	4.1							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
PERIPHERAL BLD SMEAR REVIEW  13808	301	RC	85008	CPT				Both			75	33.75	3.05	67.5	3.05							Fee Schedule		3.82							Fee Schedule		3.53							Fee Schedule		3.43							Fee Schedule											67.5							Fee Schedule																				3.43							Fee Schedule																				
RENAL FAILURE WITHOUT CC/MCC					684	DRG		Inpatient			35908.47	16158.81	16158.81	16158.81							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period							0		No services provided during 15 month lookback period				1886.68	1886.68	1886.68	1 through 10									0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period	
KIDNEY AND URINARY TRACT INFECTIONS WITH MCC					689	DRG		Inpatient			32844.22	14779.9	14779.9	14779.9							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period. 				10135.92	10135.92	10135.92	1 through 10									0		No services provided during 15 month lookback period				6779.08	6779.08	6779.08	1 through 10									0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period				4085.3	4085.3	4085.3	1 through 10									0		No services provided during 15 month lookback							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period	
KIDNEY AND URINARY TRACT INFECTIONS WITHOUT MCC					690	DRG		Inpatient			25512.52	11480.63	3.19	11480.63							0		No services performed during 15 month lookback period. 				7042.17	4590.3	17344.5	1 through 10						2729.09	2729.09	2729.09	1 through 10						1562.04	1562.04	1562.04	1 through 10						4804.74	3270.3	6996.19	1 through 10									0		No services provided during 15 month lookback period	3.94						0	Fee Schedule	No services provided during 15 month lookback period	3.19			3003.98	3003.98	3003.98	1 through 10	Fee Schedule								0		No services provided during 15 month lookback	3.94			6748.33	6748.33	6748.33	1 through 10	Fee Schedule		3.19						0	Fee Schedule	No services provided during 15 month lookback period	
URINARY STONES WITHOUT MCC					694	DRG		Inpatient			20818.08	9368.14	9368.14	9368.14							0		No services performed during 15 month lookback period. 				4321.54	4321.54	4321.54	1 through 10									0		No services performed during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period	
KIDNEY AND URINARY TRACT SIGNS AND SYMPTOMS WITHOUT MCC					696	DRG		Inpatient			19454.84	8754.68	8754.68	8754.68							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period	
PERMA HAND BLACK 3-0 C053D INSPIRE	272	RC						Both			35	15.75	15.75	31.5	22.75							Fee Schedule		25.9							Fee Schedule																													31.5							Fee Schedule																																															
PERMETHRIN 5% CREAM-60 GM	250	RC	A9270	CPT				Both			92.14	41.46	0.01	82.93	0.01							Fee Schedule		68.18							Fee Schedule																													82.93							Fee Schedule																																															
PERPHENAZINE 2MG TABLET	250	RC	A9270	CPT				Both			2.1	0.95	0.01	1.89	0.01							Fee Schedule		1.55							Fee Schedule																													1.89							Fee Schedule																																															
PESSARY #1 MXPRS01 (COOPER)	272	RC	A4562	CPT				Both			225	101.25	46.09	202.5	46.09							Fee Schedule		166.5							Fee Schedule		75.15							Fee Schedule																				202.5							Fee Schedule																																															
PESSARY #2 2-1/4  MXPRS02 (COOPER)	272	RC	A4562	CPT				Both			186	83.7	46.09	167.4	46.09							Fee Schedule		137.64							Fee Schedule		75.15							Fee Schedule																				167.4							Fee Schedule																																															
PESSARY #2 W/ KNOB MXPRSK02 (COOPER)	272	RC	A4562	CPT				Both			190	85.5	46.09	171	46.09							Fee Schedule		140.6							Fee Schedule		75.15							Fee Schedule																				171							Fee Schedule																																															
PESSARY #3 MXPRS03 (COOPER)	272	RC	A4562	CPT				Both			237	106.65	46.09	213.3	46.09							Fee Schedule		175.38							Fee Schedule		75.15							Fee Schedule											72.96							Fee Schedule		213.3							Fee Schedule		83.9							Fee Schedule		67.85							Fee Schedule											83.9							Fee Schedule		67.85							Fee Schedule		
PESSARY #3 W/ KNOB MXPRSK03 (COOPER)	272	RC	A4562	CPT				Both			190	85.5	46.09	171	46.09							Fee Schedule		140.6							Fee Schedule		75.15							Fee Schedule											72.96							Fee Schedule		171							Fee Schedule		83.9							Fee Schedule		67.85							Fee Schedule											83.9							Fee Schedule		67.85							Fee Schedule		
PESSARY #4 MXPRS04 (COOPER)	272	RC	A4562	CPT				Both			225	101.25	46.09	202.5	46.09							Fee Schedule		166.5							Fee Schedule		75.15							Fee Schedule											72.96							Fee Schedule		202.5							Fee Schedule		83.9							Fee Schedule		67.85							Fee Schedule											83.9							Fee Schedule		67.85							Fee Schedule		
PESSARY #5  MXPRS05  ( COOPER SURGICAL	272	RC	A4562	CPT				Both			237	106.65	46.09	213.3	46.09							Fee Schedule		175.38							Fee Schedule		75.15							Fee Schedule											72.96							Fee Schedule		213.3							Fee Schedule		83.9							Fee Schedule		67.85							Fee Schedule											83.9							Fee Schedule		67.85							Fee Schedule		
PESSARY #5 W/ KNOB MXPRSK05 (COOPER)	272	RC	A4562	CPT				Both			219	98.55	46.09	197.1	46.09							Fee Schedule		162.06							Fee Schedule		75.15							Fee Schedule											72.96							Fee Schedule		197.1							Fee Schedule		83.9							Fee Schedule		67.85							Fee Schedule											83.9							Fee Schedule		67.85							Fee Schedule		
PESSARY #6 MXPRS06 (COOPER SURGICAL)	272	RC	A4562	CPT				Both			237	106.65	46.09	213.3	46.09							Fee Schedule		175.38							Fee Schedule		75.15							Fee Schedule											72.96							Fee Schedule		213.3							Fee Schedule		83.9							Fee Schedule		67.85							Fee Schedule											83.9							Fee Schedule		67.85							Fee Schedule		
PESSARY #6 MXPRS06 (COOPER SURGICAL)	272	RC	A4562	CPT				Both			225	101.25	46.09	202.5	46.09							Fee Schedule		166.5							Fee Schedule		75.15							Fee Schedule											72.96							Fee Schedule		202.5							Fee Schedule		83.9							Fee Schedule		67.85							Fee Schedule											83.9							Fee Schedule		67.85							Fee Schedule		
PESSARY #6 W/ KNOB  MXPRSK06 ( COOPER S	272	RC	A4562	CPT				Both			190	85.5	46.09	171	46.09							Fee Schedule		140.6							Fee Schedule		75.15							Fee Schedule											72.96							Fee Schedule		171							Fee Schedule		83.9							Fee Schedule		67.85							Fee Schedule											83.9							Fee Schedule		67.85							Fee Schedule		
PESSARY 2 3/4 MXPCONDS03 (COOPER)	272	RC	A4562	CPT				Both			230	103.5	46.09	207	46.09							Fee Schedule		170.2							Fee Schedule		75.15							Fee Schedule											72.96							Fee Schedule		207							Fee Schedule		83.9							Fee Schedule		67.85							Fee Schedule											83.9							Fee Schedule		67.85							Fee Schedule		
PESSARY 2-1/2  SHAATZ ( COOPER SURG)	272	RC	A4562	CPT				Both			150	67.5	46.09	135	46.09							Fee Schedule		111							Fee Schedule		75.15							Fee Schedule											72.96							Fee Schedule		135							Fee Schedule		83.9							Fee Schedule		67.85							Fee Schedule											83.9							Fee Schedule		67.85							Fee Schedule		
PESSARY 2-3/4  SHAATZ ( COOPER SURG)	272	RC	A4562	CPT				Both			150	67.5	46.09	135	46.09							Fee Schedule		111							Fee Schedule		75.15							Fee Schedule											72.96							Fee Schedule		135							Fee Schedule		83.9							Fee Schedule		67.85							Fee Schedule											83.9							Fee Schedule		67.85							Fee Schedule		
PESSARY 3  SHAATZ MXPSH3-	272	RC	A4562	CPT				Both			174	78.3	46.09	156.6	46.09							Fee Schedule		128.76							Fee Schedule		75.15							Fee Schedule											72.96							Fee Schedule		156.6							Fee Schedule		83.9							Fee Schedule		67.85							Fee Schedule											83.9							Fee Schedule		67.85							Fee Schedule		
PESSARY 3-1/2  SHAATZ MXPSH3-1/2	272	RC	A4562	CPT				Both			174	78.3	46.09	156.6	46.09							Fee Schedule		128.76							Fee Schedule		75.15							Fee Schedule											72.96							Fee Schedule		156.6							Fee Schedule		83.9							Fee Schedule		67.85							Fee Schedule											83.9							Fee Schedule		67.85							Fee Schedule		
PESSARY 3-3/4 INCH  MXPDO07	271	RC	A4562	CPT				Both			162.25	73.01	46.09	146.03	46.09							Fee Schedule		120.07							Fee Schedule		75.15							Fee Schedule											72.96							Fee Schedule		146.03							Fee Schedule		83.9							Fee Schedule		67.85							Fee Schedule											83.9							Fee Schedule		67.85							Fee Schedule		
PESSARY DONUT 3IN MXPDO04 (COOPER)	272	RC	A4562	CPT				Both			230	103.5	46.09	207	46.09							Fee Schedule		170.2							Fee Schedule		75.15							Fee Schedule											72.96							Fee Schedule		207							Fee Schedule		83.9							Fee Schedule		67.85							Fee Schedule											83.9							Fee Schedule		67.85							Fee Schedule		
PESSARY DONUT MXPDO05 (COOPER)	272	RC	A4562	CPT				Both			230	103.5	46.09	207	46.09							Fee Schedule		170.2							Fee Schedule		75.15							Fee Schedule											72.96							Fee Schedule		207							Fee Schedule		83.9							Fee Schedule		67.85							Fee Schedule											83.9							Fee Schedule		67.85							Fee Schedule		
PESSARY SIZE 13/4 MXPER00 ( COOPER)	272	RC	A4562	CPT				Both			219	98.55	46.09	197.1	46.09							Fee Schedule		162.06							Fee Schedule		75.15							Fee Schedule											72.96							Fee Schedule		197.1							Fee Schedule		83.9							Fee Schedule		67.85							Fee Schedule											83.9							Fee Schedule		67.85							Fee Schedule		
PESSARY SIZE 2 MXPER01 ( COOPER)	272	RC	A4562	CPT				Both			219	98.55	46.09	197.1	46.09							Fee Schedule		162.06							Fee Schedule		75.15							Fee Schedule											72.96							Fee Schedule		197.1							Fee Schedule		83.9							Fee Schedule		67.85							Fee Schedule											83.9							Fee Schedule		67.85							Fee Schedule		
PESSARY TRIMO-SAN 4 OZ MX5030 ( COOPER S	272	RC						Both			85	38.25	38.25	83.9	55.25							Fee Schedule		62.9							Fee Schedule																				72.96							Fee Schedule		76.5							Fee Schedule		83.9							Fee Schedule		67.85							Fee Schedule											83.9							Fee Schedule		67.85							Fee Schedule		
PFT  SPIROMETRY	460	RC	94010	CPT				Both			283.5	127.58	12.81	318	200							Per Diem		209.79							Fee Schedule											12.81							Fee Schedule		72.96							Fee Schedule		255.15							Fee Schedule		83.9							Fee Schedule		67.85							Fee Schedule		318							Per Diem		83.9							Fee Schedule		67.85							Fee Schedule		
PFT FILTER DR BURTON KIT #478-187192	270	RC						Both			6	2.7	2.7	83.9	3.9							Fee Schedule		4.44							Fee Schedule																				72.96							Fee Schedule		5.4							Fee Schedule		83.9							Fee Schedule		67.85							Fee Schedule											83.9							Fee Schedule		67.85							Fee Schedule		
PFT FILTER ECO BVF KIT #FIL3500	270	RC						Both			10	4.5	4.5	9	6.5							Fee Schedule		7.4							Fee Schedule																													9							Fee Schedule																																															
PFT FLOW VOL /LOOP	460	RC	94375	CPT				Both			315	141.75	14.92	318	200							Per Diem		233.1							Fee Schedule											14.92							Fee Schedule											283.5							Fee Schedule																				318							Per Diem																				
PFT FLOW VOL/ LOOP  PRE/POST	460	RC	94060	CPT				Both			315	141.75	28.35	318	200							Per Diem		233.1							Fee Schedule											28.35							Fee Schedule											283.5							Fee Schedule																				318							Per Diem																				
PFT PREVENT FILTER  536719-001	270	RC						Both			7	3.15	3.15	6.3	4.55							Fee Schedule		5.18							Fee Schedule																													6.3							Fee Schedule																																															
PFT PREVENT FLOW SENSOR  758100-004	270	RC						Both			29	13.05	13.05	26.1	18.85							Fee Schedule		21.46							Fee Schedule																													26.1							Fee Schedule																																															
PFT SENSOR TRI-ANIM 772-29-7954EA	271	RC						Both			7	3.15	3.15	6.3	4.55							Fee Schedule		5.18							Fee Schedule																													6.3							Fee Schedule																																															
PH	301	RC	82800	CPT				Both			43.05	19.37	7.92	38.75	7.92							Fee Schedule		11							Fee Schedule		11.33							Fee Schedule		11							Fee Schedule											38.75							Fee Schedule																				11							Fee Schedule																				
PH FLUID 5367	301	RC	83986	CPT				Both			150.15	67.57	3.18	135.14	3.18							Fee Schedule		3.98							Fee Schedule		3.69							Fee Schedule		3.58							Fee Schedule											135.14							Fee Schedule																				3.58							Fee Schedule																				
PHANTOM HEADGEAR LG SLEEP NET	271	RC						Both			81.9	36.86	36.86	73.71	53.24							Fee Schedule		60.61							Fee Schedule																													73.71							Fee Schedule																																															
PHANTOM MASK (SLEEP NET)	271	RC						Both			185.85	83.63	10.23	167.27	120.8							Fee Schedule		137.53							Fee Schedule																				11							Fee Schedule		167.27							Fee Schedule		12.65							Fee Schedule		10.23							Fee Schedule											12.65							Fee Schedule		10.23							Fee Schedule		
PHASIX MESH 10X12 BARD DAVOL #1190500	278	RC	C1781	CPT				Both			12900	5805	3.33	11610		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	9546							Fee Schedule																				3.58							Fee Schedule		11610							Fee Schedule		4.12							Fee Schedule		3.33							Fee Schedule											4.12							Fee Schedule		3.33							Fee Schedule		
PHASIX ST MESH 10CM X 10CM DAVOL 1201010	278	RC	C1781	CPT				Both			5670	2551.5	2551.5	5103		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	4195.8							Fee Schedule																													5103							Fee Schedule																																															
PHASIX ST MESH 7CM X 10CM DAVOL 1200710	278	RC	C1781	CPT				Both			4561	2052.45	2052.45	4104.9		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	3375.14							Fee Schedule																													4104.9							Fee Schedule																																															
PHAZYME GELCAP	250	RC	A9270	CPT				Both			1.58	0.71	0.01	1.42	0.01							Fee Schedule		1.17							Fee Schedule																													1.42							Fee Schedule																																															
PHAZYME:125 CAPS.	250	RC	A9270	CPT				Both			1.58	0.71	0.01	1.42	0.01							Fee Schedule		1.17							Fee Schedule																													1.42							Fee Schedule																																															
PHAZYME:95 CAP	250	RC	A9270	CPT				Both			1.58	0.71	0.01	1.42	0.01							Fee Schedule		1.17							Fee Schedule																													1.42							Fee Schedule																																															
PHENAZOPYRIDINE 100MG (PYRIDIUM) TABLET	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
PHENAZOPYRIDINE 200MG (PYRIDIUM) TABLET	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
PHENERGAN : 25 MG/ML (PROMETHAZINE)	636	RC	J2550	CPT				Both			4.2	1.89	1.52	3.78		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	3.11							Fee Schedule		3.75							Fee Schedule		1.52							Fee Schedule											3.78							Fee Schedule																																															
PHENERGAN 12.5 MG RECTAL SUPPOSITORY	250	RC	A9270	CPT				Both			12.6	5.67	0.01	11.34	0.01							Fee Schedule		9.32							Fee Schedule																													11.34							Fee Schedule																																															
PHENERGAN 25 MG RECTAL SUPPOSITORY	250	RC	A9270	CPT				Both			13.65	6.14	0.01	12.29	0.01							Fee Schedule		10.1							Fee Schedule																													12.29							Fee Schedule																																															
PHENERGAN 25 MG/ML CARPUJECT	636	RC	J2550	CPT				Both			4.2	1.89	1.52	4.18		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	3.11							Fee Schedule		3.75							Fee Schedule		1.52							Fee Schedule		3.64							Fee Schedule		3.78							Fee Schedule		4.18							Fee Schedule		3.38							Fee Schedule											4.18							Fee Schedule		3.38							Fee Schedule		
PHENERGAN 50 MG RECTAL SUPPOSITORY	250	RC	A9270	CPT				Both			24.15	10.87	0.01	21.74	0.01							Fee Schedule		17.87							Fee Schedule																													21.74							Fee Schedule																																															
PHENERGAN 50 MG/ML CARPUJECT	636	RC	J2550	CPT				Both			4.2	1.89	1.52	3.78		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	3.11							Fee Schedule		3.75							Fee Schedule		1.52							Fee Schedule											3.78							Fee Schedule																																															
PHENERGAN TAB 25 MG (PROMETHAZINE)	250	RC						Both			1.58	0.71	0.71	4.18	1.03							Fee Schedule		1.17							Fee Schedule																				3.64							Fee Schedule		1.42							Fee Schedule		4.18							Fee Schedule		3.38							Fee Schedule											4.18							Fee Schedule		3.38							Fee Schedule		
PHENOBARBITAL 130 MG/ML INJECTION	636	RC	J2560	CPT				Both			7.53	3.39	3.39	25.51		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	5.57							Fee Schedule		25.51							Fee Schedule		3.7							Fee Schedule											6.78							Fee Schedule																																															
PHENOBARBITAL 20 MG/5ML ELIXIR 15ML UD	250	RC	A9270	CPT				Both			30.07	13.53	0.01	27.06	0.01							Fee Schedule		22.25							Fee Schedule																				3.64							Fee Schedule		27.06							Fee Schedule		4.18							Fee Schedule		3.38							Fee Schedule											4.18							Fee Schedule		3.38							Fee Schedule		
PHENOBARBITAL 30 MG TABLET UD	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
PHENOBARBITAL 60 MG/ML INJECTION	636	RC	J2560	CPT				Both			12.6	5.67	3.7	28.48		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	9.32							Fee Schedule		25.51							Fee Schedule		3.7							Fee Schedule		24.77							Fee Schedule		11.34							Fee Schedule		28.48							Fee Schedule		23.04							Fee Schedule											28.48							Fee Schedule		23.04							Fee Schedule		
PHENOBARBITAL 65 MG/ML INJECTION	636	RC	J2560	CPT				Both			12.6	5.67	3.7	25.51		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	9.32							Fee Schedule		25.51							Fee Schedule		3.7							Fee Schedule											11.34							Fee Schedule																																															
PHENOBARBITAL 97.2MG TABLET	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
PHENOBARBITAL QUEST 708	301	RC	80184	CPT				Both			33	14.85	11.02	29.7	11.02							Fee Schedule		15.3							Fee Schedule		15.76							Fee Schedule		15.3							Fee Schedule		24.77							Fee Schedule		29.7							Fee Schedule		28.48							Fee Schedule		23.04							Fee Schedule		15.3							Fee Schedule		28.48							Fee Schedule		23.04							Fee Schedule		
PHENOL LIQUID 100ML BOTTLE	250	RC						Both			100.7	45.32	23.04	90.63	65.46							Fee Schedule		74.52							Fee Schedule																				24.77							Fee Schedule		90.63							Fee Schedule		28.48							Fee Schedule		23.04							Fee Schedule											28.48							Fee Schedule		23.04							Fee Schedule		
PHENOLPHTHALEIN 3141 STOOL FRZ	301	RC	84311	CPT				Both			73.5	33.08	6.21	66.15	6.21							Fee Schedule		8.1							Fee Schedule		8.34							Fee Schedule		8.1							Fee Schedule											66.15							Fee Schedule																				8.1							Fee Schedule																				
PHENOTHIAZINE URINE 26509	301	RC	80307	CPT				Both			72.45	32.6	14.23	65.21	51.72							Fee Schedule		64.65							Fee Schedule		64							Fee Schedule		62.14							Fee Schedule		15.3							Fee Schedule		65.21							Fee Schedule		17.6							Fee Schedule		14.23							Fee Schedule		62.14							Fee Schedule		17.6							Fee Schedule		14.23							Fee Schedule		
PHENTOLAMINE 5 MG SDV	636	RC	J2760	CPT				Both			1575	708.75	39.12	1417.5		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	257.45							Fee Schedule		433.17							Fee Schedule		39.12							Fee Schedule											1417.5							Fee Schedule																																															
PHENYLEPHRINE 10 MG/ ML INJ	636	RC	J2371	CPT				Both			14.7	6.62	6.62	13.23		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	10.88							Fee Schedule																				8.1							Fee Schedule		13.23							Fee Schedule		9.32							Fee Schedule		7.53							Fee Schedule											9.32							Fee Schedule		7.53							Fee Schedule		
PHENYLEPHRINE 10% OPTH SOLUTION-5ML	250	RC	A9270	CPT				Both			21.11	9.5	0.01	71.46	0.01							Fee Schedule		15.62							Fee Schedule																				62.14							Fee Schedule		19							Fee Schedule		71.46							Fee Schedule		57.79							Fee Schedule											71.46							Fee Schedule		57.79							Fee Schedule		
PHENYLEPHRINE 25MG/NS 250ML DRIP	250	RC	J2371	CPT				Both			56.7	25.52	25.52	483.64	36.86							Fee Schedule		41.96							Fee Schedule																				420.56							Fee Schedule		51.03							Fee Schedule		483.64							Fee Schedule		391.12							Fee Schedule											483.64							Fee Schedule		391.12							Fee Schedule		
PHENYTOIN 1 GM/NS 100 ML IVPB	636	RC	J1165	CPT				Both			15.75	7.09	0.56	14.18		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	11.66							Fee Schedule		0.56							Fee Schedule		1.29							Fee Schedule											14.18							Fee Schedule																																															
PHENYTOIN 100 MG/2ML INJECTION	636	RC	J1165	CPT				Both			9.45	4.25	0.56	8.51		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	6.99							Fee Schedule		0.56							Fee Schedule		1.29							Fee Schedule											8.51							Fee Schedule																																															
PHENYTOIN 100 MG/4ML ORAL SUSP- UD	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
PHENYTOIN 100MG (DILANTIN) CAPSULE	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																				0.55							Fee Schedule		5.67							Fee Schedule		0.63							Fee Schedule		0.51							Fee Schedule											0.63							Fee Schedule		0.51							Fee Schedule		
PHENYTOIN 250 MG/5 ML INJECTION	636	RC	J1165	CPT				Both			11.55	5.2	0.51	10.4		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	8.55							Fee Schedule		0.56							Fee Schedule		1.29							Fee Schedule		0.55							Fee Schedule		10.4							Fee Schedule		0.63							Fee Schedule		0.51							Fee Schedule											0.63							Fee Schedule		0.51							Fee Schedule		
PHENYTOIN FREE 3189 2.5 ML SER RT	301	RC	80186	CPT				Both			84	37.8	12.23	75.6	12.23							Fee Schedule		15.29							Fee Schedule		14.17							Fee Schedule		13.76							Fee Schedule											75.6							Fee Schedule																				13.76							Fee Schedule																				
PHILADELPHIA CERV. COLLAR ADJUST ADULT	270	RC						Both			17	7.65	7.65	15.3	11.05							Fee Schedule		12.58							Fee Schedule																													15.3							Fee Schedule																																															
PHILADELPHIA CERV. COLLAR ADJUST PED	274	RC	L0170	CPT				Both			17.85	8.03	0.51	892.65		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	13.21							Fee Schedule		892.65							Fee Schedule		562.11							Fee Schedule		0.55							Fee Schedule		16.07							Fee Schedule		0.63							Fee Schedule		0.51							Fee Schedule											0.63							Fee Schedule		0.51							Fee Schedule		
PHILADELPHIA CERV. COLLAR LG #79-83147	270	RC						Both			31	13.95	12.8	27.9	20.15							Fee Schedule		22.94							Fee Schedule																				13.76							Fee Schedule		27.9							Fee Schedule		15.82							Fee Schedule		12.8							Fee Schedule											15.82							Fee Schedule		12.8							Fee Schedule		
PHILADELPHIA CERV. COLLAR MED #79-83145	270	RC						Both			30.45	13.7	13.7	27.41	19.79							Fee Schedule		22.53							Fee Schedule																													27.41							Fee Schedule																																															
PHILADELPHIA CERV. COLLAR SM #79-83143	270	RC						Both			31	13.95	13.95	996.65	20.15							Fee Schedule		22.94							Fee Schedule																				866.65							Fee Schedule		27.9							Fee Schedule		996.65							Fee Schedule		805.98							Fee Schedule											996.65							Fee Schedule		805.98							Fee Schedule		
PHILADELPHIA CHROMOSOME FISH 36063 GRN	310	RC	88237	CPT				Both			634.2	285.39	112.27	570.78	112.27							Fee Schedule		143.75							Fee Schedule		148.06							Fee Schedule		143.75							Fee Schedule											570.78							Fee Schedule																																															
PHILIPS  SELECT ANGLED GUIDEWIRE 518-087	272	RC	C1769	CPT				Both			2677.5	1204.88	154.26	2409.75	154.26							Fee Schedule		1981.35							Fee Schedule																													2409.75							Fee Schedule																																															
PHILIPS QUICK CROSS GUIDEWIRE 518-032	272	RC	C1769	CPT				Both			409.5	184.28	154.26	368.55	154.26							Fee Schedule		303.03							Fee Schedule																													368.55							Fee Schedule																																															
PHILIPS QUICK CROSS GUIDEWIRE 518-036	272	RC	C1769	CPT				Both			541.8	243.81	133.69	487.62	154.26							Fee Schedule		400.93							Fee Schedule																				143.75							Fee Schedule		487.62							Fee Schedule		165.31							Fee Schedule		133.69							Fee Schedule											165.31							Fee Schedule		133.69							Fee Schedule		
PHILIPS QUICK CROSS GUIDEWIRE 518-037	272	RC	C1769	CPT				Both			409.5	184.28	154.26	368.55	154.26							Fee Schedule		303.03							Fee Schedule																													368.55							Fee Schedule																																															
PHILIPS QUICK CROSS GUIDEWIRE 518-065	272	RC	C1769	CPT				Both			541.8	243.81	154.26	487.62	154.26							Fee Schedule		400.93							Fee Schedule																													487.62							Fee Schedule																																															
PHILLIPS FOLLOWERS10	272	RC	A4340	CPT				Both			186.9	84.11	28.59	168.21	28.59							Fee Schedule		138.31							Fee Schedule		46.61							Fee Schedule		35.74							Fee Schedule											168.21							Fee Schedule																																															
PHILLIPS FOLLOWERS14	272	RC	A4340	CPT				Both			186.9	84.11	28.59	168.21	28.59							Fee Schedule		138.31							Fee Schedule		46.61							Fee Schedule		35.74							Fee Schedule											168.21							Fee Schedule																																															
PHILLIPS FOLLOWERS16	272	RC	A4340	CPT				Both			186.9	84.11	28.59	168.21	28.59							Fee Schedule		138.31							Fee Schedule		46.61							Fee Schedule		35.74							Fee Schedule											168.21							Fee Schedule																																															
PHILLIPS FOLLOWERS18	272	RC	A4340	CPT				Both			186.9	84.11	28.59	168.21	28.59							Fee Schedule		138.31							Fee Schedule		46.61							Fee Schedule		35.74							Fee Schedule		45.25							Fee Schedule		168.21							Fee Schedule		52.04							Fee Schedule		42.08							Fee Schedule											52.04							Fee Schedule		42.08							Fee Schedule		
PHILLIPS FOLLOWERS20	272	RC	A4340	CPT				Both			186.9	84.11	28.59	168.21	28.59							Fee Schedule		138.31							Fee Schedule		46.61							Fee Schedule		35.74							Fee Schedule		45.25							Fee Schedule		168.21							Fee Schedule		52.04							Fee Schedule		42.08							Fee Schedule											52.04							Fee Schedule		42.08							Fee Schedule		
PHILLIPS FOLLOWERS22	272	RC	A4340	CPT				Both			186.9	84.11	28.59	168.21	28.59							Fee Schedule		138.31							Fee Schedule		46.61							Fee Schedule		35.74							Fee Schedule		45.25							Fee Schedule		168.21							Fee Schedule		52.04							Fee Schedule		42.08							Fee Schedule											52.04							Fee Schedule		42.08							Fee Schedule		
PHILLIPS FOLLOWERS24	272	RC	A4340	CPT				Both			186.9	84.11	28.59	168.21	28.59							Fee Schedule		138.31							Fee Schedule		46.61							Fee Schedule		35.74							Fee Schedule		45.25							Fee Schedule		168.21							Fee Schedule		52.04							Fee Schedule		42.08							Fee Schedule											52.04							Fee Schedule		42.08							Fee Schedule		
PHOS-NAK (NEUTRA-PHOS) POWDER CONC SF	250	RC	A9270	CPT				Both			6.3	2.84	0.01	52.04	0.01							Fee Schedule		4.66							Fee Schedule																				45.25							Fee Schedule		5.67							Fee Schedule		52.04							Fee Schedule		42.08							Fee Schedule											52.04							Fee Schedule		42.08							Fee Schedule		
PHOSPHA 250 NEUTRAL 250MG	250	RC	A9270	CPT				Both			6.3	2.84	0.01	52.04	0.01							Fee Schedule		4.66							Fee Schedule																				45.25							Fee Schedule		5.67							Fee Schedule		52.04							Fee Schedule		42.08							Fee Schedule											52.04							Fee Schedule		42.08							Fee Schedule		
"PHOSPHATE, RANDOM UR WO CREATININE"	301	RC	84105	CPT				Both			10.59	4.77	4.6	52.04	4.6							Fee Schedule		5.78							Fee Schedule		5.95							Fee Schedule		5.78							Fee Schedule		45.25							Fee Schedule		9.53							Fee Schedule		52.04							Fee Schedule		42.08							Fee Schedule		5.78							Fee Schedule		52.04							Fee Schedule		42.08							Fee Schedule		
PHOSPHATIDYLETHANOL (PEth) BLD 12198	302	RC	80321	CPT				Both			336	151.2	0.01	302.4	0.01							Fee Schedule									Other	No Additional Reimbursement 																												302.4							Fee Schedule																																															
"PHOSPHATIDYLserine (IGG, IGM) 11447"	302	RC	83516	CPT				Both			126	56.7	10.25	113.4	10.25							Fee Schedule		12.81							Fee Schedule		11.88							Fee Schedule		11.53							Fee Schedule											113.4							Fee Schedule																				11.53							Fee Schedule																				
PHOSPHATIDYLSERINE AB IGA 10163	302	RC	86148	CPT				Both			87.15	39.22	5.38	78.44	14.28							Fee Schedule		17.85							Fee Schedule		16.55							Fee Schedule		16.07							Fee Schedule		5.78							Fee Schedule		78.44							Fee Schedule		6.65							Fee Schedule		5.38							Fee Schedule		16.07							Fee Schedule		6.65							Fee Schedule		5.38							Fee Schedule		
PHOSPHATIDYLSERINE AB IGG & IGM 10062	302	RC	86148	CPT				Both			87.15	39.22	14.28	78.44	14.28							Fee Schedule		17.85							Fee Schedule		16.55							Fee Schedule		16.07							Fee Schedule											78.44							Fee Schedule																				16.07							Fee Schedule																				
PHOSPHOLIPIDS 717 ANTIPHOSPHOLIPIDS	302	RC	86147	CPT				Both			71.4	32.13	10.72	64.26	22.62							Fee Schedule		28.28							Fee Schedule		26.21							Fee Schedule		25.45							Fee Schedule		11.53							Fee Schedule		64.26							Fee Schedule		13.26							Fee Schedule		10.72							Fee Schedule		25.45							Fee Schedule		13.26							Fee Schedule		10.72							Fee Schedule		
PHOSPHORUS	301	RC	84100	CPT				Both			27.3	12.29	4.21	24.57	4.21							Fee Schedule		5.27							Fee Schedule		4.88							Fee Schedule		4.74							Fee Schedule		16.07							Fee Schedule		24.57							Fee Schedule		18.48							Fee Schedule		14.95							Fee Schedule		4.74							Fee Schedule		18.48							Fee Schedule		14.95							Fee Schedule		
PHOSPHORUS URINE 24 HR 719	301	RC	84105	CPT				Both			45.15	20.32	4.6	40.64	4.6							Fee Schedule		5.78							Fee Schedule		5.95							Fee Schedule		5.78							Fee Schedule		16.07							Fee Schedule		40.64							Fee Schedule		18.48							Fee Schedule		14.95							Fee Schedule		5.78							Fee Schedule		18.48							Fee Schedule		14.95							Fee Schedule		
PHYSOSTIGMINE 1MG/ML-2ML AMP	250	RC	A9270	CPT				Both			296.1	133.25	0.01	266.49	0.01							Fee Schedule		219.11							Fee Schedule																				25.45							Fee Schedule		266.49							Fee Schedule		29.27							Fee Schedule		23.67							Fee Schedule											29.27							Fee Schedule		23.67							Fee Schedule		
PHYTONADIONE (MEPHYTON) 5 MG TAB	250	RC	A9270	CPT				Both			221.55	99.7	0.01	199.4	0.01							Fee Schedule		163.95							Fee Schedule																				4.74							Fee Schedule		199.4							Fee Schedule		5.45							Fee Schedule		4.41							Fee Schedule											5.45							Fee Schedule		4.41							Fee Schedule		
PICC LINE 4F SINGLE UPICS-4.0-CT-NT-1111	278	RC	C1751	CPT				Both			434.7	195.62	5.38	391.23		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	321.68							Fee Schedule																				5.78							Fee Schedule		391.23							Fee Schedule		6.65							Fee Schedule		5.38							Fee Schedule											6.65							Fee Schedule		5.38							Fee Schedule		
PICC LINE 5FR DUAL SAF UPICDSY-5.0-CT-NT	278	RC	C1751	CPT				Both			472.5	212.63	212.63	425.25		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	349.65							Fee Schedule																													425.25							Fee Schedule																																															
PICC LINE 8 FR POWER PORT PICDS-601-MPIS	278	RC	C1751	CPT				Both			1572.9	707.81	707.81	1415.61		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1163.95							Fee Schedule																													1415.61							Fee Schedule																																															
PICC LINE INSERTION			36569	CPT				Both			315	141.75	134.54	283.5	134.54							Fee Schedule		233.1							Fee Schedule																													283.5							Fee Schedule																																															
PICC POWER 5 FR. DUAL  0720515 ( BARD  )	278	RC	C1751	CPT				Both			1533	689.85	689.85	1379.7		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1134.42							Fee Schedule																													1379.7							Fee Schedule																																															
PICC POWER SINGLE 5 FR. #0700515 ( BARD	278	RC	C1751	CPT				Both			856.8	385.56	385.56	771.12		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	634.03							Fee Schedule																													771.12							Fee Schedule																																															
PICC PROVENA 3FR SINGLE 3CG  S1173108D4	272	RC	C1751	CPT				Both			764	343.8	69.11	687.6	69.11							Fee Schedule		565.36							Fee Schedule																													687.6							Fee Schedule																																															
PICC PROVENA 4FR. DUAL 3CG  S1274108D4	278	RC	C1751	CPT				Both			789	355.05	355.05	710.1		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	583.86							Fee Schedule																													710.1							Fee Schedule																																															
PICC PROVENA 5FR DUAL S1275108D4 (DISC.)	278	RC	C1751	CPT				Both			1031.94	464.37	464.37	928.75		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	763.64							Fee Schedule																													928.75							Fee Schedule																																															
PICC PROVENA 5FR. TRIPLE 3CG  S1385108D4	278	RC	C1751	CPT				Both			845	380.25	380.25	760.5		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	625.3							Fee Schedule																													760.5							Fee Schedule																																															
PILL SPLITTER-SINGLE USE ONLY	270	RC						Both			2.1	0.95	0.95	1.89	1.37							Fee Schedule		1.55							Fee Schedule																													1.89							Fee Schedule																																															
PILLCAM SB3 CAPSOCAM PLUS #2795-5	750	RC	91110	CPT				Both			1350	607.5	502.44	1215	656.27							Fee Schedule		999							Fee Schedule											502.44							Fee Schedule											1215							Fee Schedule																																															
PILOCARPINE 0.5% OPTHL SOLN-15ML	250	RC	A9270	CPT				Both			20.85	9.38	0.01	18.77	0.01							Fee Schedule		15.43							Fee Schedule																													18.77							Fee Schedule																																															
PILOCARPINE 1% OPTHL SOLN-15ML	250	RC	A9270	CPT				Both			28.98	13.04	0.01	26.08	0.01							Fee Schedule		21.45							Fee Schedule																													26.08							Fee Schedule																																															
PILOCARPINE 2% OPTH SOLUTION	250	RC	A9270	CPT				Both			27.3	12.29	0.01	24.57	0.01							Fee Schedule		20.2							Fee Schedule																													24.57							Fee Schedule																																															
PILOCARPINE 2% OPTHL SOLN-15ML	250	RC	A9270	CPT				Both			78.75	35.44	0.01	70.88	0.01							Fee Schedule		58.28							Fee Schedule																													70.88							Fee Schedule																																															
PILOCARPINE 4% OPTHL SOLN-15ML	250	RC	A9270	CPT				Both			52.5	23.63	0.01	47.25	0.01							Fee Schedule		38.85							Fee Schedule																													47.25							Fee Schedule																																															
PINHEADS	272	RC						Both			13.65	6.14	6.14	12.29	8.87							Fee Schedule		10.1							Fee Schedule																													12.29							Fee Schedule																																															
PINK PAD XL W/ LG ARM PROT. 40687  XODUS	271	RC						Both			329	148.05	148.05	296.1	213.85							Fee Schedule		243.46							Fee Schedule																													296.1							Fee Schedule																																															
PINK PAD XL W/ STANDARD ARM PROT. #40585	271	RC						Both			414	186.3	186.3	372.6	269.1							Fee Schedule		306.36							Fee Schedule																													372.6							Fee Schedule																																															
PINK PERMA TYPE TAPE  (SENECA MEDICAL)	270	RC						Both			18.11	8.15	8.15	16.3	11.77							Fee Schedule		13.4							Fee Schedule																													16.3							Fee Schedule																																															
PINSYNC PS16	272	RC						Both			17	7.65	7.65	15.3	11.05							Fee Schedule		12.58							Fee Schedule																													15.3							Fee Schedule																																															
PIN-X CHEWABLE TABLET	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
PIP EXT ASSIST AA	270	RC						Both			31.34	14.1	14.1	28.21	20.37							Fee Schedule		23.19							Fee Schedule																													28.21							Fee Schedule																																															
PIP/ TAZO 3.375GM(SOLUSET/SYR PUMP)VIAL	636	RC	J2543	CPT				Both			65.27	29.37	1.25	58.74		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	48.3							Fee Schedule		1.25							Fee Schedule																				58.74							Fee Schedule																																															
PIPER IPPB (TRI-ANIM)	272	RC						Both			174.3	78.44	78.44	156.87	113.3							Fee Schedule		128.98							Fee Schedule																													156.87							Fee Schedule																																															
PIPERACILLIN/TAZOBACT 2.25GM/NS 50ML	636	RC	J2543	CPT				Both			64.38	28.97	1.25	57.94		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	47.64							Fee Schedule		1.25							Fee Schedule																				57.94							Fee Schedule																																															
PIPERACILLIN/TAZOBACT 3.375GM PREMIX	636	RC	J2543	CPT				Both			75.6	34.02	1.13	68.04		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	55.94							Fee Schedule		1.25							Fee Schedule											1.22							Fee Schedule		68.04							Fee Schedule		1.4							Fee Schedule		1.13							Fee Schedule											1.4							Fee Schedule		1.13							Fee Schedule		
PIPERACILLIN/TAZOBACT 3.375GM/NS 100ML	636	RC	J2543	CPT				Both			72.42	32.59	1.25	65.18		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	53.59							Fee Schedule		1.25							Fee Schedule																				65.18							Fee Schedule																																															
PIPERACILLIN/TAZOBACT 4.5 GM PREMIX	636	RC	J2543	CPT				Both			94.5	42.53	1.13	85.05		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	69.93							Fee Schedule		1.25							Fee Schedule											1.22							Fee Schedule		85.05							Fee Schedule		1.4							Fee Schedule		1.13							Fee Schedule											1.4							Fee Schedule		1.13							Fee Schedule		
PIPERACILLIN/TAZOBACT 4.5GM/NS 100ML	636	RC	J2543	CPT				Both			72.42	32.59	1.13	65.18		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	53.59							Fee Schedule		1.25							Fee Schedule											1.22							Fee Schedule		65.18							Fee Schedule		1.4							Fee Schedule		1.13							Fee Schedule											1.4							Fee Schedule		1.13							Fee Schedule		
PIPERACILLIN/TAZOBACTAM 2.25GM VIAL	636	RC	J2543	CPT				Both			43.5	19.58	1.13	39.15		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	32.19							Fee Schedule		1.25							Fee Schedule											1.22							Fee Schedule		39.15							Fee Schedule		1.4							Fee Schedule		1.13							Fee Schedule											1.4							Fee Schedule		1.13							Fee Schedule		
PIPERACILLIN/TAZOBACTAM 3.375GM VIAL	636	RC	J2543	CPT				Both			51.54	23.19	1.13	46.39		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	38.14							Fee Schedule		1.25							Fee Schedule											1.22							Fee Schedule		46.39							Fee Schedule		1.4							Fee Schedule		1.13							Fee Schedule											1.4							Fee Schedule		1.13							Fee Schedule		
PIPERACILLIN/TAZOBACTAM 4.5GM VIAL	636	RC	J2543	CPT				Both			65.25	29.36	1.13	58.73		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	48.29							Fee Schedule		1.25							Fee Schedule											1.22							Fee Schedule		58.73							Fee Schedule		1.4							Fee Schedule		1.13							Fee Schedule											1.4							Fee Schedule		1.13							Fee Schedule		
PIPERACILLIN-TAZO 2.25GM/50ML DUPLEX	636	RC	J2543	CPT				Both			63.32	28.49	1.13	56.99		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	46.86							Fee Schedule		1.25							Fee Schedule											1.22							Fee Schedule		56.99							Fee Schedule		1.4							Fee Schedule		1.13							Fee Schedule											1.4							Fee Schedule		1.13							Fee Schedule		
PIPERACILLIN-TAZO 3.375GM/50ML DUPLEX	636	RC	J2543	CPT				Both			82.23	37	1.13	74.01		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	60.85							Fee Schedule		1.25							Fee Schedule											1.22							Fee Schedule		74.01							Fee Schedule		1.4							Fee Schedule		1.13							Fee Schedule											1.4							Fee Schedule		1.13							Fee Schedule		
PIPERACILLIN-TAZO 4.5GM/100ML DUPLEX	636	RC	J2543	CPT				Both			101.12	45.5	1.13	91.01		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	74.83							Fee Schedule		1.25							Fee Schedule											1.22							Fee Schedule		91.01							Fee Schedule		1.4							Fee Schedule		1.13							Fee Schedule											1.4							Fee Schedule		1.13							Fee Schedule		
PIPRACIL 2 GM VIAL	250	RC						Both			33.85	15.23	1.13	30.47	22							Fee Schedule		25.05							Fee Schedule																				1.22							Fee Schedule		30.47							Fee Schedule		1.4							Fee Schedule		1.13							Fee Schedule											1.4							Fee Schedule		1.13							Fee Schedule		
PIPRACIL 2GM ADV	250	RC						Both			64.29	28.93	1.13	57.86	41.79							Fee Schedule		47.57							Fee Schedule																				1.22							Fee Schedule		57.86							Fee Schedule		1.4							Fee Schedule		1.13							Fee Schedule											1.4							Fee Schedule		1.13							Fee Schedule		
PIPRACIL 3 GM VIAL	250	RC						Both			51.85	23.33	1.13	46.67	33.7							Fee Schedule		38.37							Fee Schedule																				1.22							Fee Schedule		46.67							Fee Schedule		1.4							Fee Schedule		1.13							Fee Schedule											1.4							Fee Schedule		1.13							Fee Schedule		
PIPRACIL 3GM ADV	250	RC						Both			79.29	35.68	35.68	71.36	51.54							Fee Schedule		58.67							Fee Schedule																													71.36							Fee Schedule																																															
PIPRACIL 4 GM VIAL	250	RC						Both			64.47	29.01	29.01	58.02	41.91							Fee Schedule		47.71							Fee Schedule																													58.02							Fee Schedule																																															
PIRANHA BIOPSY FORCEPS #M0065051600	272	RC						Both			1050	472.5	472.5	945	682.5							Fee Schedule		777							Fee Schedule																													945							Fee Schedule																																															
PIROXICAM 20 MG CAPSULE UD	250	RC	A9270	CPT				Both			7.35	3.31	0.01	6.62	0.01							Fee Schedule		5.44							Fee Schedule																													6.62							Fee Schedule																																															
PISTON IRRI. SYRINGE NO TIP DYND20324	272	RC						Both			3	1.35	1.35	2.7	1.95							Fee Schedule		2.22							Fee Schedule																													2.7							Fee Schedule																																															
PITOCIN 1AMP	636	RC	J2590	CPT				Both			4.2	1.89	1.58	3.78		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	3.11							Fee Schedule											1.58							Fee Schedule											3.78							Fee Schedule																																															
PITOCIN 20 UNITS/1000ML NS	258	RC	J2590	CPT				Both			46.2	20.79	0.81	41.58	0.81							Fee Schedule		34.19							Fee Schedule											1.58							Fee Schedule											41.58							Fee Schedule																																															
PITOCIN 30 UNITS/NS 500ML IVPB	636	RC	J2590	CPT				Both			54.6	24.57	1.58	49.14		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	40.4							Fee Schedule											1.58							Fee Schedule											49.14							Fee Schedule																																															
PITOCIN 30 UNITS/NS 500ML PREMIX	636	RC	J2590	CPT				Both			54.6	24.57	1.58	49.14		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	40.4							Fee Schedule											1.58							Fee Schedule											49.14							Fee Schedule																																															
PKU	301	RC	84030	CPT				Both			100.8	45.36	4.89	90.72	4.89							Fee Schedule		6.11							Fee Schedule		5.67							Fee Schedule		5.5							Fee Schedule											90.72							Fee Schedule																				5.5							Fee Schedule																				
PLAIN 0 S104	272	RC						Both			11.55	5.2	5.2	10.4	7.51							Fee Schedule		8.55							Fee Schedule																													10.4							Fee Schedule																																															
PLAIN 1.0 L104G	272	RC						Both			12.6	5.67	5.67	11.34	8.19							Fee Schedule		9.32							Fee Schedule																													11.34							Fee Schedule																																															
PLAIN 1-0 S105H	272	RC						Both			10.5	4.73	4.73	9.45	6.83							Fee Schedule		7.77							Fee Schedule																				5.5							Fee Schedule		9.45							Fee Schedule		6.33							Fee Schedule		5.12							Fee Schedule											6.33							Fee Schedule		5.12							Fee Schedule		
PLAIN 2-0 872H	272	RC						Both			10	4.5	4.5	9	6.5							Fee Schedule		7.4							Fee Schedule																													9							Fee Schedule																																															
PLAIN 3.0 842H	272	RC						Both			10	4.5	4.5	9	6.5							Fee Schedule		7.4							Fee Schedule																													9							Fee Schedule																																															
PLAIN 3-0 #SG2T	272	RC						Both			60	27	27	54	39							Fee Schedule		44.4							Fee Schedule																													54							Fee Schedule																																															
PLAIN 4-0 U207H	272	RC						Both			11	4.95	4.95	9.9	7.15							Fee Schedule		8.14							Fee Schedule																													9.9							Fee Schedule																																															
PLAIN GUT 1-0 S105H	272	RC						Both			10	4.5	4.5	9	6.5							Fee Schedule		7.4							Fee Schedule																													9							Fee Schedule																																															
PLAIN GUT 2-0 N863H	272	RC						Both			10	4.5	4.5	9	6.5							Fee Schedule		7.4							Fee Schedule																													9							Fee Schedule																																															
PLAIN GUT 3.0 52T *DISC*	272	RC						Both			25.2	11.34	11.34	22.68	16.38							Fee Schedule		18.65							Fee Schedule																													22.68							Fee Schedule																																															
PLAIN GUT 3-0 H822H *DISC*	272	RC						Both			12	5.4	5.4	10.8	7.8							Fee Schedule		8.88							Fee Schedule																													10.8							Fee Schedule																																															
PLAIN GUT 4.0 U207	272	RC						Both			11.55	5.2	5.2	10.4	7.51							Fee Schedule		8.55							Fee Schedule																													10.4							Fee Schedule																																															
PLAIN GUT 4-0 1824H	272	RC						Both			12	5.4	5.4	10.8	7.8							Fee Schedule		8.88							Fee Schedule																													10.8							Fee Schedule																																															
PLAIN GUT 4-0 H821H *DISC*	272	RC						Both			12	5.4	5.4	10.8	7.8							Fee Schedule		8.88							Fee Schedule																													10.8							Fee Schedule																																															
PLAIN GUT 6.0 1916G *DISC*	272	RC						Both			21	9.45	9.45	18.9	13.65							Fee Schedule		15.54							Fee Schedule																													18.9							Fee Schedule																																															
PLAIN S-105H - 50691	272	RC						Both			10	4.5	4.5	9	6.5							Fee Schedule		7.4							Fee Schedule																													9							Fee Schedule																																															
PLAN B 0.75MG  (LEVONORGESTREL) TABLET	250	RC	A9272	CPT				Both			75.6	34.02	34.02	68.04	43.12							Fee Schedule		55.94							Fee Schedule																													68.04							Fee Schedule																																															
PLASMA HEMOGLOBIN 514 (SODIUM HEPARIN)	301	RC	83051	CPT				Both			65.1	29.3	6.5	58.59	6.5							Fee Schedule		8.12							Fee Schedule		7.53							Fee Schedule		7.31							Fee Schedule											58.59							Fee Schedule																				7.31							Fee Schedule																				
PLASMABAND ELECTRODE BIPOLAR 12 WA22721S	272	RC						Both			1286	578.7	578.7	1157.4	835.9							Fee Schedule		951.64							Fee Schedule																													1157.4							Fee Schedule																																															
PLASMALOOP ELECTRODE BIPOLAR LG WA22703S	272	RC						Both			1523	685.35	685.35	1370.7	989.95							Fee Schedule		1127.02							Fee Schedule																													1370.7							Fee Schedule																																															
PLASMALOOP ELECTRODE BIPOLAR MD WA22702S	272	RC						Both			1523	685.35	6.8	1370.7	989.95							Fee Schedule		1127.02							Fee Schedule																				7.31							Fee Schedule		1370.7							Fee Schedule		8.41							Fee Schedule		6.8							Fee Schedule											8.41							Fee Schedule		6.8							Fee Schedule		
PLASMANATE 250CC	636	RC	P9045	CPT				Both			236.25	106.31	46.01	212.63		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	46.01							Fee Schedule		54.67							Fee Schedule		47.67							Fee Schedule											212.63							Fee Schedule																																															
PLASMANATE 5%/500 ML	636	RC	P9045	CPT				Both			373.28	167.98	46.01	335.95		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	46.01							Fee Schedule		54.67							Fee Schedule		47.67							Fee Schedule											335.95							Fee Schedule																																															
PLASMANATE 50CC	250	RC						Both			78.75	35.44	35.44	70.88	51.19							Fee Schedule		58.28							Fee Schedule																													70.88							Fee Schedule																																															
PLASMINOGEN ACTIV IN  PAI-1 4G/5G  11368	310	RC	81400	CPT				Both			1459.5	656.78	46.05	1313.55	46.05							Fee Schedule		63.96							Fee Schedule		65.88							Fee Schedule		63.96							Fee Schedule		53.08							Fee Schedule		1313.55							Fee Schedule		61.04							Fee Schedule		49.36							Fee Schedule											61.04							Fee Schedule		49.36							Fee Schedule		
PLASMINOGEN ACTIVATOR IN  PAI-1 36555	305	RC	85415	CPT				Both			163.8	73.71	15.28	147.42	15.28							Fee Schedule		19.1							Fee Schedule		17.71							Fee Schedule		17.19							Fee Schedule		53.08							Fee Schedule		147.42							Fee Schedule		61.04							Fee Schedule		49.36							Fee Schedule		17.19							Fee Schedule		61.04							Fee Schedule		49.36							Fee Schedule		
PLASTALUME FINGE SPLINTS 79-73213	270	RC						Both			1.05	0.47	0.47	0.95	0.68							Fee Schedule		0.78							Fee Schedule																													0.95							Fee Schedule																																															
PLASTALUME FINGE SPLINTS 79-73217	270	RC						Both			4.2	1.89	1.89	73.55	2.73							Fee Schedule		3.11							Fee Schedule																				63.96							Fee Schedule		3.78							Fee Schedule		73.55							Fee Schedule		59.48							Fee Schedule											73.55							Fee Schedule		59.48							Fee Schedule		
PLASTALUME FINGER SPLINTS 79-73211	270	RC						Both			3	1.35	1.35	19.77	1.95							Fee Schedule		2.22							Fee Schedule																				17.19							Fee Schedule		2.7							Fee Schedule		19.77							Fee Schedule		15.99							Fee Schedule											19.77							Fee Schedule		15.99							Fee Schedule		
PLASTER SP 4	270	RC						Both			4.2	1.89	1.89	3.78	2.73							Fee Schedule		3.11							Fee Schedule																													3.78							Fee Schedule																																															
PLASTER SP 4  RL	274	RC	A4580	CPT				Both			5.25	2.36	2.36	23.72		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	3.89							Fee Schedule											23.72							Fee Schedule											4.73							Fee Schedule																																															
PLASTER SPL 2  ROLL 7362	270	RC	A4580	CPT				Both			2	0.9	0.9	23.72	9							Fee Schedule		1.48							Fee Schedule											23.72							Fee Schedule											1.8							Fee Schedule																																															
PLASTER SPL 3  ROLL #7363  (SENECA)	271	RC	A4580	CPT				Both			3	1.35	1.35	23.72	9							Fee Schedule		2.22							Fee Schedule											23.72							Fee Schedule											2.7							Fee Schedule																																															
PLASTER SPL 3 #7393 DR BOWMAN (SENECA)	271	RC	A4580	CPT				Both			1.05	0.47	0.47	23.72	9							Fee Schedule		0.78							Fee Schedule											23.72							Fee Schedule											0.95							Fee Schedule																																															
PLASTER SPL 4  ROLL #7367 (SENECA)	271	RC	A4580	CPT				Both			4.2	1.89	1.89	23.72	9							Fee Schedule		3.11							Fee Schedule											23.72							Fee Schedule											3.78							Fee Schedule																																															
PLASTER SPL 4 #7391 DR BOWMAN (SENECA)	271	RC	A4580	CPT				Both			1.05	0.47	0.47	23.72	9							Fee Schedule		0.78							Fee Schedule											23.72							Fee Schedule											0.95							Fee Schedule																																															
PLASTER SPL 5 7392 DR BOWMAN (SENECA)	271	RC	A4580	CPT				Both			1	0.45	0.45	23.72	9							Fee Schedule		0.74							Fee Schedule											23.72							Fee Schedule											0.9							Fee Schedule																																															
PLASTI BELL	272	RC						Both			7.35	3.31	3.31	6.62	4.78							Fee Schedule		5.44							Fee Schedule																													6.62							Fee Schedule																																															
PLATELET COUNT	305	RC	85049	CPT				Both			45.15	20.32	3.98	40.64	3.98							Fee Schedule		4.97							Fee Schedule		4.61							Fee Schedule		4.48							Fee Schedule											40.64							Fee Schedule																				4.48							Fee Schedule																				
PLAVIX 75 MG  (CLOPIDOGREL) TABLET	250	RC	A9270	CPT				Both			18.9	8.51	0.01	17.01	0.01							Fee Schedule		13.99							Fee Schedule																													17.01							Fee Schedule																																															
PLEDGETT PATCH	278	RC						Both			141.75	63.79	63.79	127.58		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	104.9							Fee Schedule																													127.58							Fee Schedule																																															
OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH MCC					698	DRG		Inpatient			26407.73	11883.48	11883.48	11883.48							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period				438.8	438.8	438.8	1 through 10						11010.02	11010.02	11010.02	1 through 10									0		No services provided during 15 month lookback period							0	Fee Schedule	No services provided during 15 month lookback period							0	Fee Schedule	No services provided during 15 month lookback period							0		No services provided during 15 month lookback							0		No services provided during 15 month lookback period							0	Fee Schedule	No services provided during 15 month lookback period	
OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH CC					699	DRG		Inpatient			21311.1	9590	9590	9590				3948.57	3948.57	3948.57	1 through 10						4957.7	4957.7	4957.7	1 through 10									0		No services performed during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period	
PLEXI PULSE FOOT AND CALF WRAP #28900016	271	RC	C1884	CPT				Both			157.5	70.88	70.88	141.75	134.45							Fee Schedule		116.55							Fee Schedule																													141.75							Fee Schedule																																															
PLEXI PULSE FOOT GARMENT FG200R (HUNTLEI	271	RC						Both			112.35	50.56	50.56	101.12	73.03							Fee Schedule		83.14							Fee Schedule																													101.12							Fee Schedule																																															
PLEXI PULSE FOOT WRAP #DVT-60 (HUNTLEIGH	271	RC						Both			58.8	26.46	26.46	52.92	38.22							Fee Schedule		43.51							Fee Schedule																													52.92							Fee Schedule																																															
PLEXIPULSE FOOT WRAP (KCI)	271	RC						Both			315	141.75	141.75	283.5	204.75							Fee Schedule		233.1							Fee Schedule																													283.5							Fee Schedule																																															
PM SCLERODERMA  AB 37103 1ML SERUM	300	RC	86235	CPT				Both			170.1	76.55	15.94	153.09	15.94							Fee Schedule		19.93							Fee Schedule		18.47							Fee Schedule		17.93							Fee Schedule											153.09							Fee Schedule																				17.93							Fee Schedule																				
PNEUMO NEEDLE PN 120	272	RC						Both			84	37.8	37.8	75.6	54.6							Fee Schedule		62.16							Fee Schedule																													75.6							Fee Schedule																																															
PNEUMOCYSTIS CARINII 34286 SPUTUM	306	RC	87299	CPT				Both			186.9	84.11	11.59	168.21	11.59							Fee Schedule		16.1							Fee Schedule		16.58							Fee Schedule		16.1							Fee Schedule											168.21							Fee Schedule																				16.1							Fee Schedule																				
PNEUMONEEDLE 150MM	272	RC						Both			115.5	51.98	16.67	103.95	75.08							Fee Schedule		85.47							Fee Schedule																				17.93							Fee Schedule		103.95							Fee Schedule		20.62							Fee Schedule		16.67							Fee Schedule											20.62							Fee Schedule		16.67							Fee Schedule		
PNEUMONIAE IGG ABS 13 SEROTYPE 16374	302	RC	86317	CPT				Both			27.3	12.29	12.29	24.57	13.32							Fee Schedule		16.65							Fee Schedule		15.44							Fee Schedule		14.99							Fee Schedule											24.57							Fee Schedule																				14.99							Fee Schedule																				
PNEUMONIAE IGG ABS 14 SEROTYPES 19564	302	RC	86317	CPT				Both			27.3	12.29	12.29	24.57	13.32							Fee Schedule		16.65							Fee Schedule		15.44							Fee Schedule		14.99							Fee Schedule		16.1							Fee Schedule		24.57							Fee Schedule		18.52							Fee Schedule		14.97							Fee Schedule		14.99							Fee Schedule		18.52							Fee Schedule		14.97							Fee Schedule		
PNEUMONIAE IGG ABS 23 SEROTYPES 13550	302	RC	86317	CPT				Both			36.65	16.49	13.32	32.99	13.32							Fee Schedule		16.65							Fee Schedule		15.44							Fee Schedule		14.99							Fee Schedule											32.99							Fee Schedule																				14.99							Fee Schedule																				
PNEUMONIAE IGG ABS 23 SEROTYPES 16963	302	RC	86581	CPT				Both			723	325.35	13.94	650.7	469.95							Fee Schedule		92.03							Fee Schedule		94.79							Fee Schedule		92.03							Fee Schedule		14.99							Fee Schedule		650.7							Fee Schedule		17.24							Fee Schedule		13.94							Fee Schedule											17.24							Fee Schedule		13.94							Fee Schedule		
PNEUMOTHORAX KIT SAFETY #ASK-01500-JCM	272	RC						Both			569	256.05	13.94	512.1	369.85							Fee Schedule		421.06							Fee Schedule																				14.99							Fee Schedule		512.1							Fee Schedule		17.24							Fee Schedule		13.94							Fee Schedule											17.24							Fee Schedule		13.94							Fee Schedule		
OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITHOUT CC/MCC					700	DRG		Inpatient			11615.14	5226.81	5226.81	5226.81							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0	Fee Schedule	No services provided during 15 month lookback period							0	Fee Schedule	No services provided during 15 month lookback period							0		No services provided during 15 month lookback							0		No services provided during 15 month lookback period							0	Fee Schedule	No services provided during 15 month lookback period	
PNEUMOTUSSIN HC	250	RC	A9270	CPT				Both			5.92	2.66	0.01	105.83	0.01							Fee Schedule		4.38							Fee Schedule																				92.03							Fee Schedule		5.33							Fee Schedule		105.83							Fee Schedule		85.59							Fee Schedule											105.83							Fee Schedule		85.59							Fee Schedule		
PNEUMOVAX 23 25 MCG/0.5ML INJECTION	636	RC	90732	CPT				Both			117.6	52.92	20.3	137.48		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	87.02							Fee Schedule		137.48							Fee Schedule		20.3							Fee Schedule											105.84							Fee Schedule																																															
PNU IMUNE 1 DOSE SYR	636	RC	90732	CPT				Both			42.5	19.13	19.13	137.48		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	31.45							Fee Schedule		137.48							Fee Schedule		20.3							Fee Schedule											38.25							Fee Schedule																																															
POCKET PEAK FLOW METER (TRI-ANIM)	271	RC						Both			33.6	15.12	15.12	30.24	21.84							Fee Schedule		24.86							Fee Schedule																													30.24							Fee Schedule																																															
MAJOR MALE PELVIC PROCEDURES WITHOUT CC/MCC					708	DRG		Inpatient			93689.55	42160.3	42160.3	42160.3							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0	Fee Schedule	No services provided during 15 month lookback period							0	Fee Schedule	No services provided during 15 month lookback period							0		No services provided during 15 month lookback							0		No services provided during 15 month lookback period							0	Fee Schedule	No services provided during 15 month lookback period	
TESTES PROCEDURES WITHOUT CC/MCC					712	DRG		Inpatient			13312.48	5990.61	5990.61	5990.61							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0	Fee Schedule	No services provided during 15 month lookback period							0	Fee Schedule	No services provided during 15 month lookback period							0		No services provided during 15 month lookback							0		No services provided during 15 month lookback period				1253.18	1253.18	1253.18	1 through 10	Fee Schedule		
POLIOVAX SYRINGE	636	RC	90713	CPT				Both			69.84	31.43	31.43	62.86		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	51.68							Fee Schedule											56.83							Fee Schedule											62.86							Fee Schedule																																															
POLYETHYLENE GLYCOL POWDER-238GM	250	RC	A9270	CPT				Both			34.65	15.59	0.01	31.19	0.01							Fee Schedule		25.64							Fee Schedule																													31.19							Fee Schedule																																															
POLYMEM 2X2  FILM DOT DRESSING #203	272	RC						Both			2	0.9	0.9	1.8	1.3							Fee Schedule		1.48							Fee Schedule																													1.8							Fee Schedule																																															
POLYMEM 3.5X4.5 FILM ISLAND DRESSING 405	272	RC						Both			12	5.4	5.4	10.8	7.8							Fee Schedule		8.88							Fee Schedule																													10.8							Fee Schedule																																															
POLYMEM CAVITY FILLER 5733	272	RC	A6219	CPT				Both			17.85	8.03	0.86	16.07	0.86							Fee Schedule		13.21							Fee Schedule		1.4							Fee Schedule		1.08							Fee Schedule											16.07							Fee Schedule																																															
POLYMEM DRESS 5X5	272	RC						Both			21	9.45	9.45	18.9	13.65							Fee Schedule		15.54							Fee Schedule																													18.9							Fee Schedule																																															
POLYMEM ISLAND DRESSING 3412	272	RC	A6219	CPT				Both			17	7.65	0.86	15.3	0.86							Fee Schedule		12.58							Fee Schedule		1.4							Fee Schedule		1.08							Fee Schedule											15.3							Fee Schedule																																															
POLYMEM NON-ADHESIVE 5045   4.5X4.5	272	RC	A6219	CPT				Both			33.6	15.12	0.86	30.24	0.86							Fee Schedule		24.86							Fee Schedule		1.4							Fee Schedule		1.08							Fee Schedule		1.36							Fee Schedule		30.24							Fee Schedule		1.56							Fee Schedule		1.26							Fee Schedule											1.56							Fee Schedule		1.26							Fee Schedule		
POLYMIXIN/ TRIMETHOPRIM (POLYTRIM) OPTH	250	RC	A9270	CPT				Both			54.87	24.69	0.01	49.38	0.01							Fee Schedule		40.6							Fee Schedule																													49.38							Fee Schedule																																															
POLYSACC IRON 150 MG (FERREX150) CAPSULE	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																				1.36							Fee Schedule		5.67							Fee Schedule		1.56							Fee Schedule		1.26							Fee Schedule											1.56							Fee Schedule		1.26							Fee Schedule		
POLYSPORIN OPTH OINT	250	RC	A9270	CPT				Both			48.3	21.74	0.01	43.47	0.01							Fee Schedule		35.74							Fee Schedule																				1.36							Fee Schedule		43.47							Fee Schedule		1.56							Fee Schedule		1.26							Fee Schedule											1.56							Fee Schedule		1.26							Fee Schedule		
POLYSPORIN POWDER 10GM	250	RC	A9270	CPT				Both			30.4	13.68	0.01	27.36	0.01							Fee Schedule		22.5							Fee Schedule																													27.36							Fee Schedule																																															
POLYSPORIN TOPICAL OINTMENT- 30GM	250	RC	A9270	CPT				Both			18.9	8.51	0.01	17.01	0.01							Fee Schedule		13.99							Fee Schedule																													17.01							Fee Schedule																																															
POLYVITAMIN DROPS	250	RC	A9270	CPT				Both			13.2	5.94	0.01	11.88	0.01							Fee Schedule		9.77							Fee Schedule																													11.88							Fee Schedule																																															
POP EAR WICKS	272	RC						Both			6.3	2.84	2.84	5.67	4.1							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
POREX CHIN IMPLANT MEDIUM #7521	278	RC	C1874	CPT				Both			742.35	334.06	334.06	668.12		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	549.34							Fee Schedule																													668.12							Fee Schedule																																															
POREX CHIN IMPLANT SMALL #7520	278	RC	C1874	CPT				Both			742.35	334.06	334.06	668.12		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	549.34							Fee Schedule																													668.12							Fee Schedule																																															
POREX EXTERNAL VALVE #7546 (POREX)	278	RC	C1874	CPT				Both			365.4	164.43	164.43	328.86		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	270.4							Fee Schedule																													328.86							Fee Schedule																																															
POREX NASAL DORSUM #7516 (POREX)	278	RC	C1874	CPT				Both			674.1	303.35	303.35	606.69		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	498.83							Fee Schedule																													606.69							Fee Schedule																																															
POREX NASAL SHEET #9536  (POREX)	278	RC	C1874	CPT				Both			337.05	151.67	151.67	303.35		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	249.42							Fee Schedule																													303.35							Fee Schedule																																															
POREX NASAL VALVE #7545 (POREX)	278	RC	C1874	CPT				Both			393.75	177.19	177.19	354.38		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	291.38							Fee Schedule																													354.38							Fee Schedule																																															
POREX ORBITA IMPLANT #8305	278	RC	C1874	CPT				Both			1146.6	515.97	515.97	1031.94		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	848.48							Fee Schedule																													1031.94							Fee Schedule																																															
PORPHOBILINOGEN QUANT 6329 UR RAND	301	RC	84106	CPT				Both			55.65	25.04	4.19	50.09	4.19							Fee Schedule		5.82							Fee Schedule		5.99							Fee Schedule		5.82							Fee Schedule											50.09							Fee Schedule																				5.82							Fee Schedule																				
PORPHOBILINOGEN QUANTATIVE 726 24H URI	301	RC	84110	CPT				Both			56.7	25.52	7.5	51.03	7.5							Fee Schedule		9.38							Fee Schedule		8.69							Fee Schedule		8.44							Fee Schedule											51.03							Fee Schedule																				8.44							Fee Schedule																				
"PORPHYRIN, ERYTHROCYTE, W BLD 39777"	301	RC	84202	CPT				Both			417	187.65	12.75	375.3	12.75							Fee Schedule		15.94							Fee Schedule		14.78							Fee Schedule		14.35							Fee Schedule											375.3							Fee Schedule																				14.35							Fee Schedule																				
PORPHYRINS FR URINE  QUANTITATIVE 729	301	RC	84126	CPT				Both			223.65	100.64	5.41	201.29	28.16							Fee Schedule		39.11							Fee Schedule		40.28							Fee Schedule		39.11							Fee Schedule		5.82							Fee Schedule		201.29							Fee Schedule		6.69							Fee Schedule		5.41							Fee Schedule		39.11							Fee Schedule		6.69							Fee Schedule		5.41							Fee Schedule		
PORPHYRINS FRAC 5519 PLASMA  FRZ	301	RC	82542	CPT				Both			159.6	71.82	7.85	143.64	17.34							Fee Schedule		24.09							Fee Schedule		24.81							Fee Schedule		24.09							Fee Schedule		8.44							Fee Schedule		143.64							Fee Schedule		9.71							Fee Schedule		7.85							Fee Schedule		24.09							Fee Schedule		9.71							Fee Schedule		7.85							Fee Schedule		
PORPHYRINS FREE QUANT UR 24HR  729	301	RC	84120	CPT				Both			133.35	60.01	13.08	120.02	13.08							Fee Schedule		16.35							Fee Schedule		15.15							Fee Schedule		14.71							Fee Schedule		14.35							Fee Schedule		120.02							Fee Schedule		16.5							Fee Schedule		13.35							Fee Schedule		14.71							Fee Schedule		16.5							Fee Schedule		13.35							Fee Schedule		
PORPHYRINS TOTAL 8350 2.5 ML PLASMA FRZ	301	RC	84311	CPT				Both			159.6	71.82	6.21	143.64	6.21							Fee Schedule		8.1							Fee Schedule		8.34							Fee Schedule		8.1							Fee Schedule		39.11							Fee Schedule		143.64							Fee Schedule		44.98							Fee Schedule		36.37							Fee Schedule		8.1							Fee Schedule		44.98							Fee Schedule		36.37							Fee Schedule		
"PORPHYRINS, FRAC, QUAN, RAND UR 36592"	301	RC	84120	CPT				Both			51	22.95	13.08	45.9	13.08							Fee Schedule		16.35							Fee Schedule		15.15							Fee Schedule		14.71							Fee Schedule		24.09							Fee Schedule		45.9							Fee Schedule		27.7							Fee Schedule		22.4							Fee Schedule		14.71							Fee Schedule		27.7							Fee Schedule		22.4							Fee Schedule		
PORT A CATH DUAL	278	RC	C1788	CPT				Both			1020	459	13.68	918		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	754.8							Fee Schedule																				14.71							Fee Schedule		918							Fee Schedule		16.92							Fee Schedule		13.68							Fee Schedule											16.92							Fee Schedule		13.68							Fee Schedule		
PORT DRESSING CHANGE KIT #EBSITEG002	272	RC						Both			97	43.65	7.53	87.3	63.05							Fee Schedule		71.78							Fee Schedule																				8.1							Fee Schedule		87.3							Fee Schedule		9.32							Fee Schedule		7.53							Fee Schedule											9.32							Fee Schedule		7.53							Fee Schedule		
PORTA CATH	370	RC	100	CPT				Both			346.5	155.93	13.68	311.85	225.23							Fee Schedule		256.41							Fee Schedule																				14.71							Fee Schedule		311.85							Fee Schedule		16.92							Fee Schedule		13.68							Fee Schedule											16.92							Fee Schedule		13.68							Fee Schedule		
PORTA CATH INTRODUCER	272	RC						Both			123	55.35	55.35	110.7	79.95							Fee Schedule		91.02							Fee Schedule																													110.7							Fee Schedule																																															
PORTA CATH SINGLE	278	RC	A4301	CPT				Both			705	317.25	317.25	634.5		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	521.7							Fee Schedule																													634.5							Fee Schedule																																															
PORTA CATH WITH INDUCER	278	RC	A4301	CPT				Both			1395	627.75	627.75	1255.5		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1032.3							Fee Schedule																													1255.5							Fee Schedule																																															
PORTACATH 6FR POW. LOW PROFILE 1616000	278	RC	C1788	CPT				Both			1940	873	873	1746		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1435.6							Fee Schedule																													1746							Fee Schedule																																															
PORTACATH DUAL 7255 (HORIZON MEDICAL)	278	RC	A4301	CPT				Both			1020	459	459	918		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	754.8							Fee Schedule																													918							Fee Schedule																																															
PORTACATH LPS5513 (RITA MEDICAL SYSTEMS)	278	RC	C1788	CPT				Both			705	317.25	317.25	634.5		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	521.7							Fee Schedule																													634.5							Fee Schedule																																															
PORTACATH NEEDLE	272	RC						Both			15.75	7.09	7.09	14.18	10.24							Fee Schedule		11.66							Fee Schedule																													14.18							Fee Schedule																																															
PORTACATH POWER 1808060 (BARD PERIPH)	278	RC	C1788	CPT				Both			1922	864.9	864.9	1729.8		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1422.28							Fee Schedule																													1729.8							Fee Schedule																																															
PORTACATH POWER 1829500 (BARD PERIPH)	278	RC	C1788	CPT				Both			1728	777.6	777.6	1555.2		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1278.72							Fee Schedule																													1555.2							Fee Schedule																																															
PORTACATH POWER 1859660 (BARD PERIPH)	278	RC	C1788	CPT				Both			1386	623.7	623.7	1247.4		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1025.64							Fee Schedule																													1247.4							Fee Schedule																																															
"POSACONAZOLE, SERUM  13235"	301	RC	80187	CPT				Both			100	45	19.52	90	19.52							Fee Schedule		27.11							Fee Schedule		27.92							Fee Schedule		27.11							Fee Schedule											90							Fee Schedule																																															
POSEY OXIMETER PROBE WRAP 6554	270	RC						Both			30	13.5	13.5	27	19.5							Fee Schedule		22.2							Fee Schedule																													27							Fee Schedule																																															
POST OP REHAB 3 BRACE	274	RC						Both			333.9	150.26	150.26	300.51		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	247.09							Fee Schedule																													300.51							Fee Schedule																																															
POST OP SHOE FE LG #79-81167	271	RC	L3260	CPT				Both			15	6.75	6.12	31.18	6.12							Fee Schedule		11.1							Fee Schedule																				27.11							Fee Schedule		13.5							Fee Schedule		31.18							Fee Schedule		25.21							Fee Schedule											31.18							Fee Schedule		25.21							Fee Schedule		
POST OP SHOE FEM MED #79-90195	271	RC	L3260	CPT				Both			15	6.75	6.12	13.5	6.12							Fee Schedule		11.1							Fee Schedule																													13.5							Fee Schedule																																															
POST OP SHOE FEM SM #79-90193	271	RC	L3260	CPT				Both			15	6.75	6.12	13.5	6.12							Fee Schedule		11.1							Fee Schedule																													13.5							Fee Schedule																																															
POST OP SHOE MA LG #79-81137	271	RC	L3260	CPT				Both			12	5.4	5.4	10.8	6.12							Fee Schedule		8.88							Fee Schedule																													10.8							Fee Schedule																																															
POST OP SHOE MA MED #79-81135	271	RC	L3260	CPT				Both			12	5.4	5.4	10.8	6.12							Fee Schedule		8.88							Fee Schedule																													10.8							Fee Schedule																																															
POST OP SHOE MA SM #79-81133	271	RC	L3260	CPT				Both			12	5.4	5.4	10.8	6.12							Fee Schedule		8.88							Fee Schedule																													10.8							Fee Schedule																																															
POST OP SHOE MA XLG FOREFOOT OFFLOADING	271	RC	L3260	CPT				Both			78.75	35.44	6.12	70.88	6.12							Fee Schedule		58.28							Fee Schedule																													70.88							Fee Schedule																																															
POST OP SHOE PED	271	RC	L3260	CPT				Both			30.45	13.7	6.12	27.41	6.12							Fee Schedule		22.53							Fee Schedule																													27.41							Fee Schedule																																															
POST. LOWER LEG BILAT  2   ORTHO GLASS	274	RC	A4590	CPT				Both			472.5	212.63	24.09	425.25		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	349.65							Fee Schedule											24.09							Fee Schedule											425.25							Fee Schedule																																															
POST. LOWER LEG BILAT  3   ORTHO GLASS	274	RC	A4590	CPT				Both			630	283.5	24.09	567		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	466.2							Fee Schedule											24.09							Fee Schedule											567							Fee Schedule																																															
POST. LOWER LEG BILAT  4   ORTHO GLASS	274	RC	A4590	CPT				Both			787.5	354.38	24.09	708.75		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	582.75							Fee Schedule											24.09							Fee Schedule											708.75							Fee Schedule																																															
POST. LOWER LEG BILAT  5  ORTHO GLASS	274	RC	A4590	CPT				Both			945	425.25	24.09	850.5		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	699.3							Fee Schedule											24.09							Fee Schedule											850.5							Fee Schedule																																															
POST. LOWER LEG SPLT. 2   ORTHO GLASS	270	RC	A4590	CPT				Both			236.25	106.31	20.24	212.63	20.24							Fee Schedule		174.83							Fee Schedule											24.09							Fee Schedule											212.63							Fee Schedule																																															
POST. LOWER LEG SPLT. 3   ORTHO GLASS	270	RC						Both			315	141.75	141.75	283.5	204.75							Fee Schedule		233.1							Fee Schedule																													283.5							Fee Schedule																																															
POST. LOWER LEG SPLT. 4   ORTHO GLASS	270	RC						Both			393.75	177.19	177.19	354.38	255.94							Fee Schedule		291.38							Fee Schedule																													354.38							Fee Schedule																																															
POST. LOWER LEG SPLT. 5   ORTHO GLASS	270	RC	A4590	CPT				Both			472.5	212.63	20.24	425.25	20.24							Fee Schedule		349.65							Fee Schedule											24.09							Fee Schedule											425.25							Fee Schedule																																															
POSTERIOR ARM SPLING 3	270	RC						Both			267.75	120.49	120.49	240.98	174.04							Fee Schedule		198.14							Fee Schedule																													240.98							Fee Schedule																																															
POSTERIOR ARM SPLINT 2	270	RC						Both			214.2	96.39	96.39	192.78	139.23							Fee Schedule		158.51							Fee Schedule																													192.78							Fee Schedule																																															
POSTERIOR ARM SPLINT 4	274	RC						Both			321.3	144.59	144.59	289.17		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	237.76							Fee Schedule																													289.17							Fee Schedule																																															
POSTERIOR ARM SPLINT 5	274	RC	A4590	CPT				Both			374.85	168.68	24.09	337.37		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	277.39							Fee Schedule											24.09							Fee Schedule											337.37							Fee Schedule																																															
OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES EXCEPT MALIGN					718	DRG		Inpatient			34596.07	15568.23	15568.23	15568.23							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period	
INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM WITHOUT MCC					728	DRG		Inpatient			19114.77	8601.65	8601.65	8601.65							0		No services performed during 15 month lookback period. 				5289.96	5289.96	5289.96	1 through 10									0		No services performed during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period				3002.77	3002.77	3002.77	1 through 10									0		No services provided during 15 month lookback							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period	
UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITHOUT CC/					743	DRG		Inpatient			61352.39	27608.58	27608.58	27608.58							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period	
MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WIT					760	DRG		Inpatient			34906.68	15708	15708	15708							0		No services performed during 15 month lookback period. 				11769.75	11769.75	11769.75	1 through 10									0		No services performed during 15 month lookback period				3469.11	3469.11	3469.11	1 through 10									0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period	
POT CHL : 20 MEQ 10 ML	636	RC	J3480	CPT				Both			3.78	1.7	0.14	3.4		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	2.8							Fee Schedule		0.14							Fee Schedule		0.27							Fee Schedule											3.4							Fee Schedule																																															
POT CHL(10%) 20 MEQ/15 ML ORAL LIQUID	250	RC	A9270	CPT				Both			4.2	1.89	0.01	3.78	0.01							Fee Schedule		3.11							Fee Schedule																													3.78							Fee Schedule																																															
POT CHL(20%) 40MEQ/15ML ORAL LIQUID	250	RC	A9270	CPT				Both			1.58	0.71	0.01	1.42	0.01							Fee Schedule		1.17							Fee Schedule																													1.42							Fee Schedule																																															
POTAS CHLOR KCL 20MG	250	RC						Both			4.2	1.89	0.13	3.78	2.73							Fee Schedule		3.11							Fee Schedule																				0.14							Fee Schedule		3.78							Fee Schedule		0.16							Fee Schedule		0.13							Fee Schedule											0.16							Fee Schedule		0.13							Fee Schedule		
POTASSIUM	301	RC	84132	CPT				Both			90.3	40.64	4.09	81.27	4.09							Fee Schedule		5.11							Fee Schedule		4.9							Fee Schedule		4.76							Fee Schedule											81.27							Fee Schedule																				4.76							Fee Schedule																				
POTASSIUM 24 HR URN W/ CREAT 734	301	RC	84133	CPT				Both			156	70.2	3.83	140.4	3.83							Fee Schedule		4.79							Fee Schedule		4.87							Fee Schedule		4.73							Fee Schedule											140.4							Fee Schedule																				4.73							Fee Schedule																				
POTASSIUM ACETATE 40MEQ/20ML VIAL	250	RC						Both			9.45	4.25	4.25	8.51	6.14							Fee Schedule		6.99							Fee Schedule																													8.51							Fee Schedule																																															
POTASSIUM CHL 10 MEQ/50ML PREMIX IVPB	636	RC	J3480	CPT				Both			34.65	15.59	0.14	31.19		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	25.64							Fee Schedule		0.14							Fee Schedule		0.27							Fee Schedule		4.76							Fee Schedule		31.19							Fee Schedule		5.47							Fee Schedule		4.43							Fee Schedule											5.47							Fee Schedule		4.43							Fee Schedule		
POTASSIUM CHL 20 MEQ PREMIX IVPB	636	RC	J3480	CPT				Both			34.65	15.59	0.14	31.19		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	25.64							Fee Schedule		0.14							Fee Schedule		0.27							Fee Schedule		4.73							Fee Schedule		31.19							Fee Schedule		5.44							Fee Schedule		4.4							Fee Schedule											5.44							Fee Schedule		4.4							Fee Schedule		
POTASSIUM CHL 30 MEQ/100ML IVPB	636	RC	J3480	CPT				Both			12.6	5.67	0.14	11.34		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	9.32							Fee Schedule		0.14							Fee Schedule		0.27							Fee Schedule											11.34							Fee Schedule																																															
POTASSIUM CHL 40 MEQ/100ML PREMIX IVPB	258	RC	J3480	CPT				Both			12.6	5.67	0.13	11.34	0.14							Fee Schedule		9.32							Fee Schedule		0.14							Fee Schedule		0.27							Fee Schedule		0.14							Fee Schedule		11.34							Fee Schedule		0.16							Fee Schedule		0.13							Fee Schedule											0.16							Fee Schedule		0.13							Fee Schedule		
POTASSIUM CHLORIDE 20 MEQ/10ML VIAL	636	RC	J3480	CPT				Both			11.55	5.2	0.13	10.4		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	8.55							Fee Schedule		0.14							Fee Schedule		0.27							Fee Schedule		0.14							Fee Schedule		10.4							Fee Schedule		0.16							Fee Schedule		0.13							Fee Schedule											0.16							Fee Schedule		0.13							Fee Schedule		
POTASSIUM CHLORIDE 20 MEQ/15ML LIQUID UD	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																				0.14							Fee Schedule		5.67							Fee Schedule		0.16							Fee Schedule		0.13							Fee Schedule											0.16							Fee Schedule		0.13							Fee Schedule		
POTASSIUM CHLORIDE 30 MEQ/15ML VIAL	636	RC	J3480	CPT				Both			11.55	5.2	0.13	10.4		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	8.55							Fee Schedule		0.14							Fee Schedule		0.27							Fee Schedule		0.14							Fee Schedule		10.4							Fee Schedule		0.16							Fee Schedule		0.13							Fee Schedule											0.16							Fee Schedule		0.13							Fee Schedule		
POTASSIUM CHLORIDE 40 MEQ/20ML VIAL	636	RC	J3480	CPT				Both			11.55	5.2	0.13	10.4		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	8.55							Fee Schedule		0.14							Fee Schedule		0.27							Fee Schedule		0.14							Fee Schedule		10.4							Fee Schedule		0.16							Fee Schedule		0.13							Fee Schedule											0.16							Fee Schedule		0.13							Fee Schedule		
POTASSIUM CL ER 10 MEQ (MICRO K) CAPSULE	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
POTASSIUM CL ER 20 MEQ (K-DUR) TAB	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																				0.14							Fee Schedule		5.67							Fee Schedule		0.16							Fee Schedule		0.13							Fee Schedule											0.16							Fee Schedule		0.13							Fee Schedule		
POTASSIUM EFFERVESANT 25 MEQ TABLET	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																				0.14							Fee Schedule		5.67							Fee Schedule		0.16							Fee Schedule		0.13							Fee Schedule											0.16							Fee Schedule		0.13							Fee Schedule		
POTASSIUM IODIDE 1G/ML (SSKI DROPS)	250	RC	A9270	CPT				Both			401.63	180.73	0.01	361.47	0.01							Fee Schedule		297.21							Fee Schedule																													361.47							Fee Schedule																																															
POTASSIUM PHOS 15MM/5ML VIAL	250	RC	A9270	CPT				Both			86.33	38.85	0.01	77.7	0.01							Fee Schedule		63.88							Fee Schedule																													77.7							Fee Schedule																																															
POTASSIUM PHOS 15MMOL/NS 250ML IVPB	250	RC	A9270	CPT				Both			64.29	28.93	0.01	57.86	0.01							Fee Schedule		47.57							Fee Schedule																													57.86							Fee Schedule																																															
POTASSIUM PHOS 21MMOL/NS 250ML IVPB	250	RC	A9270	CPT				Both			64.29	28.93	0.01	57.86	0.01							Fee Schedule		47.57							Fee Schedule																													57.86							Fee Schedule																																															
POTASSIUM PHOS 40MMOL/NS 250ML IVPB	250	RC	A9270	CPT				Both			64.29	28.93	0.01	57.86	0.01							Fee Schedule		47.57							Fee Schedule																													57.86							Fee Schedule																																															
POTASSIUM URINE	301	RC	84133	CPT				Both			34.65	15.59	3.83	31.19	3.83							Fee Schedule		4.79							Fee Schedule		4.87							Fee Schedule		4.73							Fee Schedule											31.19							Fee Schedule																				4.73							Fee Schedule																				
POTASSIUM URINE 24 HR 11316 REF LAB	301	RC	84133	CPT				Both			56.7	25.52	3.83	51.03	3.83							Fee Schedule		4.79							Fee Schedule		4.87							Fee Schedule		4.73							Fee Schedule											51.03							Fee Schedule																				4.73							Fee Schedule																				
POVIDONE IODINE 10% OINTMENT- 30GM	250	RC	A9270	CPT				Both			9.45	4.25	0.01	8.51	0.01							Fee Schedule		6.99							Fee Schedule																													8.51							Fee Schedule																																															
POVIDONE IODINE 10% OINTMENT UD PACKET	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																				4.73							Fee Schedule		5.67							Fee Schedule		5.44							Fee Schedule		4.4							Fee Schedule											5.44							Fee Schedule		4.4							Fee Schedule		
POWER LOC SAFETY NEEDLE 19X1 #0671910	272	RC						Both			28	12.6	4.4	25.2	18.2							Fee Schedule		20.72							Fee Schedule																				4.73							Fee Schedule		25.2							Fee Schedule		5.44							Fee Schedule		4.4							Fee Schedule											5.44							Fee Schedule		4.4							Fee Schedule		
POWER LOC SAFETY NEEDLE 20X1 #0672010	272	RC						Both			28	12.6	12.6	25.2	18.2							Fee Schedule		20.72							Fee Schedule																													25.2							Fee Schedule																																															
POWER LOC SAFETY NEEDLE 20X3/4 #0672034	272	RC						Both			28	12.6	12.6	25.2	18.2							Fee Schedule		20.72							Fee Schedule																													25.2							Fee Schedule																																															
PRADAXA 150 MG CAP	250	RC	A9270	CPT				Both			27.3	12.29	0.01	24.57	0.01							Fee Schedule		20.2							Fee Schedule																													24.57							Fee Schedule																																															
PRADAXA 75 MG CAP	250	RC	A9270	CPT				Both			12.95	5.83	0.01	11.66	0.01							Fee Schedule		9.58							Fee Schedule																													11.66							Fee Schedule																																															
PRALIDOXIME 1GM VIAL	636	RC	J2730	CPT				Both			341.25	153.56	37.09	307.13		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	252.53							Fee Schedule											37.09							Fee Schedule											307.13							Fee Schedule																																															
PRAMIPEXOLE 0.125MG (MIRAPEX) TABLET	250	RC	A9270	CPT				Both			10.5	4.73	0.01	9.45	0.01							Fee Schedule		7.77							Fee Schedule																													9.45							Fee Schedule																																															
PRAMIPEXOLE 0.25MG (MIRAPEX) TABLET	250	RC	A9270	CPT				Both			5.25	2.36	0.01	4.73	0.01							Fee Schedule		3.89							Fee Schedule																													4.73							Fee Schedule																																															
PRANDIN 1 MG TABLET	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
PRAVASTATIN 10 MG TABLET UD	250	RC	A9270	CPT				Both			5.78	2.6	0.01	5.2	0.01							Fee Schedule		4.28							Fee Schedule																													5.2							Fee Schedule																																															
PRAVASTATIN 10MG TABLET	250	RC	A9270	CPT				Both			9.45	4.25	0.01	8.51	0.01							Fee Schedule		6.99							Fee Schedule																													8.51							Fee Schedule																																															
PRAVASTATIN 20MG TABLET	250	RC	A9270	CPT				Both			10.5	4.73	0.01	9.45	0.01							Fee Schedule		7.77							Fee Schedule																													9.45							Fee Schedule																																															
PRAZOSIN 1MG (MINIPRES) CAPSULE	250	RC	A9270	CPT				Both			5.25	2.36	0.01	4.73	0.01							Fee Schedule		3.89							Fee Schedule																													4.73							Fee Schedule																																															
PRE OP W/ROBINUL	250	RC						Both			13.86	6.24	6.24	12.47	9.01							Fee Schedule		10.26							Fee Schedule																													12.47							Fee Schedule																																															
PREALBUMIN SERUM	301	RC	84134	CPT				Both			68.25	30.71	12.97	61.43	12.97							Fee Schedule		16.21							Fee Schedule		15.03							Fee Schedule		14.59							Fee Schedule											61.43							Fee Schedule																				14.59							Fee Schedule																				
PRECEDEX 4MCG/ ML- 100ML VIAL (DRIP)	250	RC	A9270	CPT				Both			317.1	142.7	0.01	285.39	0.01							Fee Schedule		234.65							Fee Schedule																													285.39							Fee Schedule																																															
PRECISION XCEED PRO GLUCOSE TESTS	270	RC						Both			2.1	0.95	0.95	1.89	1.37							Fee Schedule		1.55							Fee Schedule																													1.89							Fee Schedule																																															
PRED FORTE 1% OPTH.SOL	250	RC	A9270	CPT				Both			44.1	19.85	0.01	39.69	0.01							Fee Schedule		32.63							Fee Schedule																				14.59							Fee Schedule		39.69							Fee Schedule		16.78							Fee Schedule		13.57							Fee Schedule											16.78							Fee Schedule		13.57							Fee Schedule		
PRED G OPTH SOL-5ML	250	RC	A9270	CPT				Both			63	28.35	0.01	56.7	0.01							Fee Schedule		46.62							Fee Schedule																													56.7							Fee Schedule																																															
PREDNISOLONE 15 MG/5ML ORAL SOLN UD	250	RC	A9270	CPT				Both			43.05	19.37	0.01	38.75	0.01							Fee Schedule		31.86							Fee Schedule																													38.75							Fee Schedule																																															
PREDNISOLONE 15 MG/5ML SYRUP UD	250	RC	J7510	CPT				Both			10.5	4.73	0.09	9.45	0.09							Fee Schedule		7.77							Fee Schedule		0.8							Fee Schedule																				9.45							Fee Schedule																																															
PREDNISOLONE 5 MG/5 ML ORAL SOLUTION UD	250	RC	J7510	CPT				Both			6.3	2.84	0.09	5.67	0.09							Fee Schedule		4.66							Fee Schedule		0.8							Fee Schedule																				5.67							Fee Schedule																																															
PredNISolone 5 MG/5ML ORAL SOLUTION UD	250	RC	A9270	CPT				Both			8.4	3.78	0.01	7.56	0.01							Fee Schedule		6.22							Fee Schedule																													7.56							Fee Schedule																																															
PredNISolone 5 mg/5ml SYRUP UD	250	RC	A9270	CPT				Both			5.25	2.36	0.01	4.73	0.01							Fee Schedule		3.89							Fee Schedule																				0.78							Fee Schedule		4.73							Fee Schedule		0.89							Fee Schedule		0.72							Fee Schedule											0.89							Fee Schedule		0.72							Fee Schedule		
PREDNISOLONE 50MG	636	RC	J2650	CPT				Both			3.78	1.7	0.72	3.4		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	2.8							Fee Schedule																				0.78							Fee Schedule		3.4							Fee Schedule		0.89							Fee Schedule		0.72							Fee Schedule											0.89							Fee Schedule		0.72							Fee Schedule		
PREDNISOLONE ACETATE 1% OPTH SUSP-5ML	250	RC	A9270	CPT				Both			174.26	78.42	0.01	156.83	0.01							Fee Schedule		128.95							Fee Schedule																													156.83							Fee Schedule																																															
PREDNISONE  1 MG TABLET	250	RC	J7512	CPT				Both			5.25	2.36	0.01	4.73	0.01							Fee Schedule		3.89							Fee Schedule																													4.73							Fee Schedule																																															
PREDNISONE  5 MG TABLET	250	RC	J7512	CPT				Both			5.25	2.36	0.01	4.73	0.01							Fee Schedule		3.89							Fee Schedule																													4.73							Fee Schedule																																															
PREDNISONE 10 MG TABLET	250	RC	A9270	CPT				Both			5.25	2.36	0.01	4.73	0.01							Fee Schedule		3.89							Fee Schedule																													4.73							Fee Schedule																																															
PREDNISONE 10 MG TABS	250	RC						Both			1.58	0.71	0.71	1.42	1.03							Fee Schedule		1.17							Fee Schedule																													1.42							Fee Schedule																																															
PREDNISONE 20 MG TABLET	250	RC	A9270	CPT				Both			5.25	2.36	0.01	4.73	0.01							Fee Schedule		3.89							Fee Schedule																													4.73							Fee Schedule																																															
PREDNISONE 20MG TAB	250	RC						Both			1.58	0.71	0.71	1.42	1.03							Fee Schedule		1.17							Fee Schedule																													1.42							Fee Schedule																																															
PREDNISONE 5 MG/5 ML SOLUTION UD	636	RC	J7510	CPT				Both			12.6	5.67	0.8	11.34		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	9.32							Fee Schedule		0.8							Fee Schedule																				11.34							Fee Schedule																																															
PREGABALIN (LYRICA) 100MG CAPSULE	250	RC	A9270	CPT				Both			6	2.7	0.01	5.4	0.01							Fee Schedule		4.44							Fee Schedule																													5.4							Fee Schedule																																															
PREGABALIN (LYRICA) 25MG CAPSULE	250	RC	A9270	CPT				Both			24.15	10.87	0.01	21.74	0.01							Fee Schedule		17.87							Fee Schedule																													21.74							Fee Schedule																																															
PREGABALIN (LYRICA) 75MG  CAPSULE	250	RC	A9270	CPT				Both			26.25	11.81	0.01	23.63	0.01							Fee Schedule		19.43							Fee Schedule																				0.78							Fee Schedule		23.63							Fee Schedule		0.89							Fee Schedule		0.72							Fee Schedule											0.89							Fee Schedule		0.72							Fee Schedule		
PREGNANCY TEST 395097A	270	RC						Both			10	4.5	4.5	9	6.5							Fee Schedule		7.4							Fee Schedule																													9							Fee Schedule																																															
PREGNANCY TEST UR QUAL	301	RC	84703	CPT				Both			135.45	60.95	6.69	121.91	6.69							Fee Schedule		8.36							Fee Schedule		7.75							Fee Schedule		7.52							Fee Schedule											121.91							Fee Schedule																				7.52							Fee Schedule																				
PREGNENOLONE  LC MS MS 31493	301	RC	84140	CPT				Both			155.4	69.93	18.37	139.86	18.37							Fee Schedule		22.97							Fee Schedule		21.29							Fee Schedule		20.67							Fee Schedule											139.86							Fee Schedule																				20.67							Fee Schedule																				
PRELONE 15 MG/5 ML SYRUP	636	RC	J7510	CPT				Both			8	3.6	0.8	7.2		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	5.92							Fee Schedule		0.8							Fee Schedule																				7.2							Fee Schedule																																															
PREMARIN 0.3 MG TABS	250	RC	A9270	CPT				Both			5.25	2.36	0.01	8.65	0.01							Fee Schedule		3.89							Fee Schedule																				7.52							Fee Schedule		4.73							Fee Schedule		8.65							Fee Schedule		6.99							Fee Schedule											8.65							Fee Schedule		6.99							Fee Schedule		
PREMARIN 0.625 MG TABLET	250	RC	A9270	CPT				Both			16.13	7.26	0.01	23.77	0.01							Fee Schedule		11.94							Fee Schedule																				20.67							Fee Schedule		14.52							Fee Schedule		23.77							Fee Schedule		19.22							Fee Schedule											23.77							Fee Schedule		19.22							Fee Schedule		
PREMARIN 0.9 MG TABLET	250	RC	A9270	CPT				Both			5.25	2.36	0.01	4.73	0.01							Fee Schedule		3.89							Fee Schedule																				0.78							Fee Schedule		4.73							Fee Schedule		0.89							Fee Schedule		0.72							Fee Schedule											0.89							Fee Schedule		0.72							Fee Schedule		
PREMARIN 1.25 MG TABLET	250	RC	A9270	CPT				Both			5.25	2.36	0.01	4.73	0.01							Fee Schedule		3.89							Fee Schedule																													4.73							Fee Schedule																																															
PREMARIN 25 MG VIAL	636	RC	J1410	CPT				Both			199.5	89.78	41.27	403.51		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	391.72							Fee Schedule		403.51							Fee Schedule		41.27							Fee Schedule											179.55							Fee Schedule																																															
PREMARIN VAGINAL CREAM- 30GM	250	RC	A9270	CPT				Both			1572.99	707.85	0.01	1415.69	0.01							Fee Schedule		1164.01							Fee Schedule																													1415.69							Fee Schedule																																															
VAGINAL DELIVERY WITH O.R. PROCEDURES EXCEPT STERILIZATION A					768	DRG		Inpatient			10881.21	4896.55	4896.55	4896.55							0		No services performed during 15 month lookback period. 				2422.43	2422.43	2422.43	1 through 10									0		No services performed during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period				7745.8	7745.8	7745.8	1 through 10									0		No services provided during 15 month lookback period				4097.62	4097.62	4097.62	1 through 10									0		No services provided during 15 month lookback							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period	
PREMPRO 0.625/2.5 MG TABLET	250	RC	A9270	CPT				Both			4.2	1.89	0.01	450.53	0.01							Fee Schedule		3.11							Fee Schedule																				391.76							Fee Schedule		3.78							Fee Schedule		450.53							Fee Schedule		364.34							Fee Schedule											450.53							Fee Schedule		364.34							Fee Schedule		
PRENATAL VITAMIN TABLET	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
PREPARATION H RECTAL SUPPOSITORY	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
PRESSURE LINE ADAPTOR #1642	270	RC						Both			2	0.9	0.9	1.8	1.3							Fee Schedule		1.48							Fee Schedule																													1.8							Fee Schedule																																															
PRESSURE MONITORING KIT  PX260	272	RC						Both			26.25	11.81	11.81	23.63	17.06							Fee Schedule		19.43							Fee Schedule																													23.63							Fee Schedule																																															
PREVACID 15 MG CAPSULE UD	250	RC	A9270	CPT				Both			10.9	4.91	0.01	9.81	0.01							Fee Schedule		8.07							Fee Schedule																													9.81							Fee Schedule																																															
PREVACID 30 MG CAPSULE UD	250	RC	A9270	CPT				Both			11.03	4.96	0.01	9.93	0.01							Fee Schedule		8.16							Fee Schedule																													9.93							Fee Schedule																																															
PREVACID 30 MG PACKETTE	250	RC	A9270	CPT				Both			13.49	6.07	0.01	12.14	0.01							Fee Schedule		9.98							Fee Schedule																													12.14							Fee Schedule																																															
PREVACID 30 MG SOLUTAB	250	RC	A9270	CPT				Both			12.6	5.67	0.01	11.34	0.01							Fee Schedule		9.32							Fee Schedule																													11.34							Fee Schedule																																															
PREVNAR 13 (0.5ML SYRINGE)	636	RC	90670	CPT				Both			215.25	96.86	96.86	193.73		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	159.29							Fee Schedule																													193.73							Fee Schedule																																															
PREVNAR 20 (0.5ML SYRINGE)	636	RC	90677	CPT				Both			895.95	403.18	351.23	806.36		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	663							Fee Schedule		351.23							Fee Schedule																				806.36							Fee Schedule																																															
PRILOSEC (OMEPRAZOLE) CAP	250	RC	A9270	CPT				Both			10.88	4.9	0.01	9.79	0.01							Fee Schedule		8.05							Fee Schedule																													9.79							Fee Schedule																																															
PRIMAQUINE 26.3 MG (PHOSPHATE)	250	RC	A9270	CPT				Both			3.15	1.42	0.01	2.84	0.01							Fee Schedule		2.33							Fee Schedule																													2.84							Fee Schedule																																															
PRIMARY SET #2C8537 (CENTRAL SUPPLY)	272	RC						Both			11	4.95	4.95	392.15	7.15							Fee Schedule		8.14							Fee Schedule																				341							Fee Schedule		9.9							Fee Schedule		392.15							Fee Schedule		317.13							Fee Schedule											392.15							Fee Schedule		317.13							Fee Schedule		
PRIMARY SET CLEARLINK	272	RC						Both			28.35	12.76	12.76	25.52	18.43							Fee Schedule		20.98							Fee Schedule																													25.52							Fee Schedule																																															
PRIMAXIN  250 MG/NS 100 ML IVPB	636	RC	J0743	CPT				Both			26.25	11.81	6.71	23.63		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	19.43							Fee Schedule		6.71							Fee Schedule		17.1							Fee Schedule											23.63							Fee Schedule																																															
PRIMAXIN  500 MG/NS 100 ML IVPB	636	RC	J0743	CPT				Both			47.25	21.26	6.71	42.53		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	34.97							Fee Schedule		6.71							Fee Schedule		17.1							Fee Schedule											42.53							Fee Schedule																																															
PRIMAXIN  750 MG/NS 100 ML IVPB	636	RC	J0743	CPT				Both			125.48	56.47	6.71	112.93		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	92.86							Fee Schedule		6.71							Fee Schedule		17.1							Fee Schedule											112.93							Fee Schedule																																															
PRIMAXIN 1000 MG/NS 100 ML IVPB	636	RC	J0743	CPT				Both			125.48	56.47	6.06	112.93		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	92.86							Fee Schedule		6.71							Fee Schedule		17.1							Fee Schedule		6.52							Fee Schedule		112.93							Fee Schedule		7.49							Fee Schedule		6.06							Fee Schedule											7.49							Fee Schedule		6.06							Fee Schedule		
PRIMAXIN 10MG/NS 100 ML IVPB	636	RC	J0743	CPT				Both			47.25	21.26	6.06	42.53		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	34.97							Fee Schedule		6.71							Fee Schedule		17.1							Fee Schedule		6.52							Fee Schedule		42.53							Fee Schedule		7.49							Fee Schedule		6.06							Fee Schedule											7.49							Fee Schedule		6.06							Fee Schedule		
PRIMAXIN 125MG/NS 100 ML IVPB	636	RC	J0743	CPT				Both			17.01	7.65	6.06	17.1		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	12.59							Fee Schedule		6.71							Fee Schedule		17.1							Fee Schedule		6.52							Fee Schedule		15.31							Fee Schedule		7.49							Fee Schedule		6.06							Fee Schedule											7.49							Fee Schedule		6.06							Fee Schedule		
PRIMAXIN 40MG/NS 100 ML IVPB	636	RC	J0743	CPT				Both			47.25	21.26	6.06	42.53		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	34.97							Fee Schedule		6.71							Fee Schedule		17.1							Fee Schedule		6.52							Fee Schedule		42.53							Fee Schedule		7.49							Fee Schedule		6.06							Fee Schedule											7.49							Fee Schedule		6.06							Fee Schedule		
PRIMAXIN 450MG/NS 100 ML IVPB	636	RC	J0743	CPT				Both			47.25	21.26	6.06	42.53		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	34.97							Fee Schedule		6.71							Fee Schedule		17.1							Fee Schedule		6.52							Fee Schedule		42.53							Fee Schedule		7.49							Fee Schedule		6.06							Fee Schedule											7.49							Fee Schedule		6.06							Fee Schedule		
PRIMAXIN VIAL  250 MG	636	RC	J0743	CPT				Both			16.8	7.56	6.06	17.1		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	12.43							Fee Schedule		6.71							Fee Schedule		17.1							Fee Schedule		6.52							Fee Schedule		15.12							Fee Schedule		7.49							Fee Schedule		6.06							Fee Schedule											7.49							Fee Schedule		6.06							Fee Schedule		
PRIMAXIN VIAL  500 MG	636	RC	J0743	CPT				Both			74.55	33.55	6.06	67.1		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	55.17							Fee Schedule		6.71							Fee Schedule		17.1							Fee Schedule		6.52							Fee Schedule		67.1							Fee Schedule		7.49							Fee Schedule		6.06							Fee Schedule											7.49							Fee Schedule		6.06							Fee Schedule		
PRIMIDONE  50MG (MYSOLINE) TABLET	250	RC	A9270	CPT				Both			5.25	2.36	0.01	7.49	0.01							Fee Schedule		3.89							Fee Schedule																				6.52							Fee Schedule		4.73							Fee Schedule		7.49							Fee Schedule		6.06							Fee Schedule											7.49							Fee Schedule		6.06							Fee Schedule		
PRIMIDONE 250MG (MYSOLINE) TABLET	250	RC	A9270	CPT				Both			5.25	2.36	0.01	7.49	0.01							Fee Schedule		3.89							Fee Schedule																				6.52							Fee Schedule		4.73							Fee Schedule		7.49							Fee Schedule		6.06							Fee Schedule											7.49							Fee Schedule		6.06							Fee Schedule		
PRIMIDONE 751 SERUM	301	RC	80188	CPT				Both			72.45	32.6	6.06	65.21	14.75							Fee Schedule		18.44							Fee Schedule		17.09							Fee Schedule		16.59							Fee Schedule		6.52							Fee Schedule		65.21							Fee Schedule		7.49							Fee Schedule		6.06							Fee Schedule		16.59							Fee Schedule		7.49							Fee Schedule		6.06							Fee Schedule		
PRINCIPEN SUSP 250	250	RC	A9270	CPT				Both			10.84	4.88	0.01	9.76	0.01							Fee Schedule		8.02							Fee Schedule																													9.76							Fee Schedule																																															
PRIORIX (MMR) VACCINE 0.5ML	636	RC	90707	CPT				Both			227.58	102.41	54.12	204.82		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	168.41							Fee Schedule											54.12							Fee Schedule											204.82							Fee Schedule																																															
PRIVIGEN 10%  5GMS/50MLVIAL	636	RC	J1459	CPT				Both			2362.5	1063.13	15.43	2126.25		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	49.53							Fee Schedule		51.79							Fee Schedule											16.59							Fee Schedule		2126.25							Fee Schedule		19.08							Fee Schedule		15.43							Fee Schedule											19.08							Fee Schedule		15.43							Fee Schedule		
PRIVIGEN 10% 10 GM/100ML VIAL	636	RC	J1459	CPT				Both			4725	2126.25	49.53	4252.5		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	49.53							Fee Schedule		51.79							Fee Schedule																				4252.5							Fee Schedule																																															
PRIVIGEN 10% 20 GM/200ML VIAL	636	RC	J1459	CPT				Both			9450	4252.5	49.53	8505		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	49.53							Fee Schedule		51.79							Fee Schedule																				8505							Fee Schedule																																															
PRIVIGEN 10% 40 GM/400ML VIAL	636	RC	J1459	CPT				Both			19950	8977.5	46.76	17955		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	49.53							Fee Schedule		51.79							Fee Schedule											50.28							Fee Schedule		17955							Fee Schedule		57.82							Fee Schedule		46.76							Fee Schedule											57.82							Fee Schedule		46.76							Fee Schedule		
PRN ADAPTER #7N8300	270	RC	A4649	CPT				Both			5	2.25	2.25	57.82	3.25							Fee Schedule		3.7							Fee Schedule																				50.28							Fee Schedule		4.5							Fee Schedule		57.82							Fee Schedule		46.76							Fee Schedule											57.82							Fee Schedule		46.76							Fee Schedule		
PRN VALVE ONE LINK #7N8399	272	RC						Both			4	1.8	1.8	57.82	2.6							Fee Schedule		2.96							Fee Schedule																				50.28							Fee Schedule		3.6							Fee Schedule		57.82							Fee Schedule		46.76							Fee Schedule											57.82							Fee Schedule		46.76							Fee Schedule		
PRO BNP	301	RC	83880	CPT				Both			256	115.2	30.17	230.4	30.17							Fee Schedule		39.26							Fee Schedule		40.44							Fee Schedule		39.26							Fee Schedule		50.28							Fee Schedule		230.4							Fee Schedule		57.82							Fee Schedule		46.76							Fee Schedule		39.26							Fee Schedule		57.82							Fee Schedule		46.76							Fee Schedule		
PRO OSTEON GRANULES (INTERPORE CROSS)	278	RC	C1762	CPT				Both			1520.4	684.18	684.18	1368.36		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1125.1							Fee Schedule																													1368.36							Fee Schedule																																															
PRO PREDICTR TPMT 37742 EDTA LAV TOP	310	RC	81401	CPT				Both			1348.2	606.69	98.64	1213.38	98.64							Fee Schedule		137							Fee Schedule		141.11							Fee Schedule		137							Fee Schedule											1213.38							Fee Schedule																																															
PROBE COVER THERMA SCAN E.R.	270	RC						Both			0.24	0.11	0.11	45.15	0.16							Fee Schedule		0.18							Fee Schedule																				39.26							Fee Schedule		0.22							Fee Schedule		45.15							Fee Schedule		36.51							Fee Schedule											45.15							Fee Schedule		36.51							Fee Schedule		
PROBE COVER UNIVERSAL W/ GEL PC1290	272	RC						Both			16	7.2	7.2	14.4	10.4							Fee Schedule		11.84							Fee Schedule																													14.4							Fee Schedule																																															
PROBENECID 500 MG TABLET UD	250	RC	A9270	CPT				Both			4.2	1.89	0.01	157.55	0.01							Fee Schedule		3.11							Fee Schedule																				137							Fee Schedule		3.78							Fee Schedule		157.55							Fee Schedule		127.41							Fee Schedule											157.55							Fee Schedule		127.41							Fee Schedule		
PROCAINAMIDE 100 MG/ML- 10ML VIAL	636	RC	J2690	CPT				Both			17.85	8.03	8.03	354.87		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	214.81							Fee Schedule		354.87							Fee Schedule		17.1							Fee Schedule											16.07							Fee Schedule																																															
PROCAINAMIDE 1000 MG/2ML VIAL	636	RC	J2690	CPT				Both			39.9	17.96	17.1	354.87		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	214.81							Fee Schedule		354.87							Fee Schedule		17.1							Fee Schedule											35.91							Fee Schedule																																															
PROCAINAMIDE 250 MG CAPSULE UD	250	RC	A9270	CPT				Both			5.25	2.36	0.01	4.73	0.01							Fee Schedule		3.89							Fee Schedule																													4.73							Fee Schedule																																															
PROCAINAMIDE 743 SERUM	301	RC	80190	CPT				Both			165.9	74.66	43.2	396.21	43.2							Fee Schedule		60							Fee Schedule		61.8							Fee Schedule		60							Fee Schedule		344.53							Fee Schedule		149.31							Fee Schedule		396.21							Fee Schedule		320.41							Fee Schedule		60							Fee Schedule		396.21							Fee Schedule		320.41							Fee Schedule		
PROCAINAMIDE 750 MG SR CAPSULE UD	250	RC	A9270	CPT				Both			4.2	1.89	0.01	396.21	0.01							Fee Schedule		3.11							Fee Schedule																				344.53							Fee Schedule		3.78							Fee Schedule		396.21							Fee Schedule		320.41							Fee Schedule											396.21							Fee Schedule		320.41							Fee Schedule		
PROCAINAMIDE W METAB 743 SERUM	301	RC	80192	CPT				Both			82.95	37.33	14.89	74.66	14.89							Fee Schedule		18.61							Fee Schedule		17.25							Fee Schedule		16.75							Fee Schedule											74.66							Fee Schedule																				16.75							Fee Schedule																				
PROCALCITONIN 16265   2ML SERUM FZ	300	RC	84145	CPT				Both			358.05	161.12	23.82	322.25	23.82							Fee Schedule		29.77							Fee Schedule		28.04							Fee Schedule		27.22							Fee Schedule		60							Fee Schedule		322.25							Fee Schedule		69							Fee Schedule		55.8							Fee Schedule		27.22							Fee Schedule		69							Fee Schedule		55.8							Fee Schedule		
PROCAN 375 MG CAPSULE	250	RC	A9270	CPT				Both			1.58	0.71	0.01	1.42	0.01							Fee Schedule		1.17							Fee Schedule																													1.42							Fee Schedule																																															
PROCAN 500 MG CAPSULE	250	RC	A9270	CPT				Both			4.2	1.89	0.01	19.26	0.01							Fee Schedule		3.11							Fee Schedule																				16.75							Fee Schedule		3.78							Fee Schedule		19.26							Fee Schedule		15.58							Fee Schedule											19.26							Fee Schedule		15.58							Fee Schedule		
PROCAN SR 500 MG TAB (PROCAINAMIDE)	250	RC	A9270	CPT				Both			1.58	0.71	0.01	31.3	0.01							Fee Schedule		1.17							Fee Schedule																				27.22							Fee Schedule		1.42							Fee Schedule		31.3							Fee Schedule		25.31							Fee Schedule											31.3							Fee Schedule		25.31							Fee Schedule		
PROCAN SR 500 MG TABLET	250	RC	A9270	CPT				Both			5.25	2.36	0.01	4.73	0.01							Fee Schedule		3.89							Fee Schedule																													4.73							Fee Schedule																																															
PROCAN SR 750 MG TAB	250	RC	A9270	CPT				Both			2.6	1.17	0.01	2.34	0.01							Fee Schedule		1.92							Fee Schedule																													2.34							Fee Schedule																																															
PROCARDIA 20 MG (NIFEDIPINE)	250	RC	A9270	CPT				Both			4.2	1.89	0.01	3.78	0.01							Fee Schedule		3.11							Fee Schedule																													3.78							Fee Schedule																																															
PROCHLORPERAZIN 10 MG/2ML(COMPAZINE) INJ	636	RC	J0780	CPT				Both			11.55	5.2	2.84	10.4		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	8.55							Fee Schedule		2.84							Fee Schedule		3.34							Fee Schedule											10.4							Fee Schedule																																															
PROCHLORPERAZINE 10 MG TABLET UD	250	RC						Both			4.2	1.89	1.89	3.78	2.73							Fee Schedule		3.11							Fee Schedule																													3.78							Fee Schedule																																															
PROCHLORPERAZINE 25 MG RECTAL SUPPOSITOR	250	RC	A9270	CPT				Both			10.5	4.73	0.01	9.45	0.01							Fee Schedule		7.77							Fee Schedule																													9.45							Fee Schedule																																															
PROCHLORPERAZINE 5MG (COMPAZINE) TABLET	250	RC	A9270	CPT				Both			5.25	2.36	0.01	4.73	0.01							Fee Schedule		3.89							Fee Schedule																				2.76							Fee Schedule		4.73							Fee Schedule		3.18							Fee Schedule		2.57							Fee Schedule											3.18							Fee Schedule		2.57							Fee Schedule		
PROCOLLAGEN TYPE 1 16609 1ML SER REF	301	RC	86316	CPT				Both			262.5	118.13	18.5	236.25	18.5							Fee Schedule		23.13							Fee Schedule		21.43							Fee Schedule		20.81							Fee Schedule											236.25							Fee Schedule																				20.81							Fee Schedule																				
"PROCRIT  2,000 UNITS/ML VIAL"	636	RC	J0885	CPT				Both			116.55	52.45	7.3	104.9		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	7.3							Fee Schedule		7.98							Fee Schedule																				104.9							Fee Schedule																																															
"PROCRIT  3,000 UNITS/ML VIAL"	636	RC	J0885	CPT				Both			173.25	77.96	7.3	155.93		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	7.3							Fee Schedule		7.98							Fee Schedule																				155.93							Fee Schedule																																															
"PROCRIT  4,000 UNITS/ML-1ML VIAL"	636	RC	J0885	CPT				Both			231	103.95	7.3	207.9		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	7.3							Fee Schedule		7.98							Fee Schedule											20.81							Fee Schedule		207.9							Fee Schedule		23.93							Fee Schedule		19.35							Fee Schedule											23.93							Fee Schedule		19.35							Fee Schedule		
"PROCRIT 10,000 UNIT/ML-1ML VIAL"	636	RC	J0885	CPT				Both			884.1	397.85	7.2	795.69		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	7.3							Fee Schedule		7.98							Fee Schedule											7.74							Fee Schedule		795.69							Fee Schedule		8.9							Fee Schedule		7.2							Fee Schedule											8.9							Fee Schedule		7.2							Fee Schedule		
"PROCRIT 20,000 UNITS/ML-1ML VIAL"	636	RC	J0885	CPT				Both			1769.04	796.07	7.2	1592.14		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	7.3							Fee Schedule		7.98							Fee Schedule											7.74							Fee Schedule		1592.14							Fee Schedule		8.9							Fee Schedule		7.2							Fee Schedule											8.9							Fee Schedule		7.2							Fee Schedule		
"PROCRIT 40,000 UNIT/ML-1ML VIAL"	636	RC	J0885	CPT				Both			3538.5	1592.33	7.2	3184.65		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	7.3							Fee Schedule		7.98							Fee Schedule											7.74							Fee Schedule		3184.65							Fee Schedule		8.9							Fee Schedule		7.2							Fee Schedule											8.9							Fee Schedule		7.2							Fee Schedule		
PROCTOFOAM HC TOPICAL AEROSOL-10GM	250	RC	A9270	CPT				Both			208.06	93.63	0.01	187.25	0.01							Fee Schedule		153.96							Fee Schedule																				7.74							Fee Schedule		187.25							Fee Schedule		8.9							Fee Schedule		7.2							Fee Schedule											8.9							Fee Schedule		7.2							Fee Schedule		
PROCTOZONE-HC  2.5% (ANUSOL HC) CREAM	250	RC	A9270	CPT				Both			275.1	123.8	0.01	247.59	0.01							Fee Schedule		203.57							Fee Schedule																				7.74							Fee Schedule		247.59							Fee Schedule		8.9							Fee Schedule		7.2							Fee Schedule											8.9							Fee Schedule		7.2							Fee Schedule		
PROFORE LITE 66000771	270	RC	A6448	CPT				Both			34.65	15.59	1.01	31.19	1.04							Fee Schedule		25.64							Fee Schedule		1.69							Fee Schedule		1.01							Fee Schedule		7.74							Fee Schedule		31.19							Fee Schedule		8.9							Fee Schedule		7.2							Fee Schedule											8.9							Fee Schedule		7.2							Fee Schedule		
PROGESTERONE 745 SERUM	301	RC	84144	CPT				Both			115.5	51.98	18.55	103.95	18.55							Fee Schedule		23.18							Fee Schedule		21.49							Fee Schedule		20.86							Fee Schedule											103.95							Fee Schedule																				20.86							Fee Schedule																				
PROGESTERONE RECEPT	301	RC	84234	CPT				Both			351.75	158.29	57.67	316.58	57.67							Fee Schedule		72.09							Fee Schedule		66.83							Fee Schedule		64.88							Fee Schedule											316.58							Fee Schedule																				64.88							Fee Schedule																				
PROINSULIN 760 1ML SERUM	301	RC	84206	CPT				Both			158.55	71.35	1.53	142.7	19.22							Fee Schedule		26.69							Fee Schedule		27.49							Fee Schedule		26.69							Fee Schedule		1.64							Fee Schedule		142.7							Fee Schedule		1.89							Fee Schedule		1.53							Fee Schedule		26.69							Fee Schedule		1.89							Fee Schedule		1.53							Fee Schedule		
PROLACTIN BY RIA 746 SERUM	301	RC	84146	CPT				Both			106.05	47.72	17.22	95.45	17.22							Fee Schedule		21.53							Fee Schedule		19.96							Fee Schedule		19.38							Fee Schedule		20.86							Fee Schedule		95.45							Fee Schedule		23.99							Fee Schedule		19.4							Fee Schedule		19.38							Fee Schedule		23.99							Fee Schedule		19.4							Fee Schedule		
PROLENE 0  8424H	272	RC						Both			9	4.05	4.05	74.61	5.85							Fee Schedule		6.66							Fee Schedule																				64.88							Fee Schedule		8.1							Fee Schedule		74.61							Fee Schedule		60.34							Fee Schedule											74.61							Fee Schedule		60.34							Fee Schedule		
PROLENE 0 #8412H	272	RC						Both			10	4.5	4.5	30.69	6.5							Fee Schedule		7.4							Fee Schedule																				26.69							Fee Schedule		9							Fee Schedule		30.69							Fee Schedule		24.82							Fee Schedule											30.69							Fee Schedule		24.82							Fee Schedule		
PROLENE 0 8418H	272	RC						Both			12	5.4	5.4	22.29	7.8							Fee Schedule		8.88							Fee Schedule																				19.38							Fee Schedule		10.8							Fee Schedule		22.29							Fee Schedule		18.02							Fee Schedule											22.29							Fee Schedule		18.02							Fee Schedule		
PROLENE 0 8434H	272	RC						Both			9	4.05	4.05	8.1	5.85							Fee Schedule		6.66							Fee Schedule																													8.1							Fee Schedule																																															
PROLENE 1 #8425H	272	RC						Both			9	4.05	4.05	8.1	5.85							Fee Schedule		6.66							Fee Schedule																													8.1							Fee Schedule																																															
PROLENE 1 #8824G	272	RC						Both			13	5.85	5.85	11.7	8.45							Fee Schedule		9.62							Fee Schedule																													11.7							Fee Schedule																																															
PROLENE 1 D9487	272	RC						Both			161	72.45	72.45	144.9	104.65							Fee Schedule		119.14							Fee Schedule																													144.9							Fee Schedule																																															
PROLENE 2-0 8423H	272	RC						Both			8	3.6	3.6	7.2	5.2							Fee Schedule		5.92							Fee Schedule																													7.2							Fee Schedule																																															
PROLENE 2-0 8523	272	RC						Both			23.1	10.4	10.4	20.79	15.02							Fee Schedule		17.09							Fee Schedule																													20.79							Fee Schedule																																															
PROLENE 2-0 8623H	272	RC						Both			11.55	5.2	5.2	10.4	7.51							Fee Schedule		8.55							Fee Schedule																													10.4							Fee Schedule																																															
PROLENE 2-0 8685G	272	RC						Both			5	2.25	2.25	4.5	3.25							Fee Schedule		3.7							Fee Schedule																													4.5							Fee Schedule																																															
PROLENE 2-0 8689H	272	RC						Both			13	5.85	5.85	11.7	8.45							Fee Schedule		9.62							Fee Schedule																													11.7							Fee Schedule																																															
PROLENE 2-0 8833H	272	RC						Both			12	5.4	5.4	10.8	7.8							Fee Schedule		8.88							Fee Schedule																													10.8							Fee Schedule																																															
PROLENE 3.0  8832H	272	RC						Both			11	4.95	4.95	9.9	7.15							Fee Schedule		8.14							Fee Schedule																													9.9							Fee Schedule																																															
PROLENE 3.0 8558H	272	RC						Both			21	9.45	9.45	18.9	13.65							Fee Schedule		15.54							Fee Schedule																													18.9							Fee Schedule																																															
PROLENE 3.0 8632G	272	RC						Both			20	9	9	18	13							Fee Schedule		14.8							Fee Schedule																													18							Fee Schedule																																															
PROLENE 3.0 8632G	272	RC						Both			20	9	9	18	13							Fee Schedule		14.8							Fee Schedule																													18							Fee Schedule																																															
PROLENE 3.0 8872H	272	RC						Both			11	4.95	4.95	9.9	7.15							Fee Schedule		8.14							Fee Schedule																													9.9							Fee Schedule																																															
PROLENE 3.0 9556 HEMASEAL	272	RC						Both			19.95	8.98	8.98	17.96	12.97							Fee Schedule		14.76							Fee Schedule																													17.96							Fee Schedule																																															
PROLENE 3-0 8410H	272	RC						Both			8	3.6	3.6	7.2	5.2							Fee Schedule		5.92							Fee Schedule																													7.2							Fee Schedule																																															
PROLENE 3-0 8522H	272	RC						Both			20	9	9	18	13							Fee Schedule		14.8							Fee Schedule																													18							Fee Schedule																																															
PROLENE 3-0 8663G	272	RC						Both			21	9.45	9.45	18.9	13.65							Fee Schedule		15.54							Fee Schedule																													18.9							Fee Schedule																																															
PROLENE 3-0 8665G	272	RC						Both			11	4.95	4.95	9.9	7.15							Fee Schedule		8.14							Fee Schedule																													9.9							Fee Schedule																																															
PROLENE 3-0 8842H	272	RC						Both			19	8.55	8.55	17.1	12.35							Fee Schedule		14.06							Fee Schedule																													17.1							Fee Schedule																																															
PROLENE 4.0 8757H	272	RC						Both			62	27.9	27.9	55.8	40.3							Fee Schedule		45.88							Fee Schedule																													55.8							Fee Schedule																																															
PROLENE 4.0 8831H	272	RC						Both			11	4.95	4.95	9.9	7.15							Fee Schedule		8.14							Fee Schedule																													9.9							Fee Schedule																																															
PROLENE 4.0 8871H	272	RC						Both			12	5.4	5.4	10.8	7.8							Fee Schedule		8.88							Fee Schedule																													10.8							Fee Schedule																																															
PROLENE 4.0 U207	272	RC						Both			6.3	2.84	2.84	5.67	4.1							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
PROLENE 4-0 8581H	272	RC						Both			20	9	9	18	13							Fee Schedule		14.8							Fee Schedule																													18							Fee Schedule																																															
PROLENE 4-0 8682G	272	RC						Both			19	8.55	8.55	17.1	12.35							Fee Schedule		14.06							Fee Schedule																													17.1							Fee Schedule																																															
PROLENE 4-0 8683G	272	RC						Both			10	4.5	4.5	9	6.5							Fee Schedule		7.4							Fee Schedule																													9							Fee Schedule																																															
PROLENE 4-0 8689	272	RC						Both			7.35	3.31	3.31	6.62	4.78							Fee Schedule		5.44							Fee Schedule																													6.62							Fee Schedule																																															
PROLENE 4-0 8699G	272	RC						Both			19	8.55	8.55	17.1	12.35							Fee Schedule		14.06							Fee Schedule																													17.1							Fee Schedule																																															
PROLENE 4-0 9706H	272	RC						Both			45.15	20.32	20.32	40.64	29.35							Fee Schedule		33.41							Fee Schedule																													40.64							Fee Schedule																																															
PROLENE 5.0 9702H	272	RC						Both			79	35.55	35.55	71.1	51.35							Fee Schedule		58.46							Fee Schedule																													71.1							Fee Schedule																																															
PROLENE 5-0  8681G	272	RC						Both			23.1	10.4	10.4	20.79	15.02							Fee Schedule		17.09							Fee Schedule																													20.79							Fee Schedule																																															
PROLENE 5-0  8686G	272	RC						Both			15	6.75	6.75	13.5	9.75							Fee Schedule		11.1							Fee Schedule																													13.5							Fee Schedule																																															
PROLENE 5-0 #8720ZH (OLD# 8720H)	272	RC						Both			38.85	17.48	17.48	34.97	25.25							Fee Schedule		28.75							Fee Schedule																													34.97							Fee Schedule																																															
PROLENE 5-0 #M8556  BLUE	272	RC						Both			56.7	25.52	25.52	51.03	36.86							Fee Schedule		41.96							Fee Schedule																													51.03							Fee Schedule																																															
PROLENE 5-0 8555H (OLD# 8555H)	272	RC						Both			7	3.15	3.15	6.3	4.55							Fee Schedule		5.18							Fee Schedule																													6.3							Fee Schedule																																															
PROLENE 5-0 8605G	272	RC						Both			20	9	9	18	13							Fee Schedule		14.8							Fee Schedule																													18							Fee Schedule																																															
PROLENE 5-0 8661G	272	RC						Both			11	4.95	4.95	9.9	7.15							Fee Schedule		8.14							Fee Schedule																													9.9							Fee Schedule																																															
PROLENE 5-0 8698G	272	RC						Both			17	7.65	7.65	15.3	11.05							Fee Schedule		12.58							Fee Schedule																													15.3							Fee Schedule																																															
PROLENE 6.0 8307H	272	RC						Both			54.6	24.57	24.57	49.14	35.49							Fee Schedule		40.4							Fee Schedule																													49.14							Fee Schedule																																															
PROLENE 6.0 8714H	272	RC						Both			19.95	8.98	8.98	17.96	12.97							Fee Schedule		14.76							Fee Schedule																													17.96							Fee Schedule																																															
PROLENE 6-0 8695G	272	RC						Both			20	9	9	18	13							Fee Schedule		14.8							Fee Schedule																													18							Fee Schedule																																															
PROLENE 6-0 8697G	272	RC						Both			23	10.35	10.35	20.7	14.95							Fee Schedule		17.02							Fee Schedule																													20.7							Fee Schedule																																															
PROLENE 6-0 8697G	272	RC						Both			20	9	9	18	13							Fee Schedule		14.8							Fee Schedule																													18							Fee Schedule																																															
PROLENE 7-0 8206H	272	RC						Both			29	13.05	13.05	26.1	18.85							Fee Schedule		21.46							Fee Schedule																													26.1							Fee Schedule																																															
PROLENE 8725H	272	RC						Both			27.3	12.29	12.29	24.57	17.75							Fee Schedule		20.2							Fee Schedule																													24.57							Fee Schedule																																															
PROLENE BLUNT 0 PB21H	272	RC						Both			12	5.4	5.4	10.8	7.8							Fee Schedule		8.88							Fee Schedule																													10.8							Fee Schedule																																															
PROLENE BLUNT 1-0 PB20H	272	RC						Both			8.4	3.78	3.78	7.56	5.46							Fee Schedule		6.22							Fee Schedule																													7.56							Fee Schedule																																															
PROLENE ER CHARGE	272	RC						Both			22.05	9.92	9.92	19.85	14.33							Fee Schedule		16.32							Fee Schedule																													19.85							Fee Schedule																																															
PROLIA 60MG/ML SYRINGE	636	RC	J0897	CPT				Both			6251.88	2813.35	29.51	5626.69		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	29.51							Fee Schedule		30.34							Fee Schedule																				5626.69							Fee Schedule																																															
PROLIA 60MG/ML SYRINGE	636	RC	J0897	CPT				Both			6251.88	2813.35	29.51	5626.69		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	29.51							Fee Schedule		30.34							Fee Schedule																				5626.69							Fee Schedule																																															
PROLIXIN 1 MG TABLET	250	RC	A9270	CPT				Both			3.15	1.42	0.01	2.84	0.01							Fee Schedule		2.33							Fee Schedule																													2.84							Fee Schedule																																															
PROLIXIN 5 MG GEN	250	RC	A9270	CPT				Both			1.58	0.71	0.01	33.88	0.01							Fee Schedule		1.17							Fee Schedule																				29.46							Fee Schedule		1.42							Fee Schedule		33.88							Fee Schedule		27.4							Fee Schedule											33.88							Fee Schedule		27.4							Fee Schedule		
PROMETHAZINE   6.25MG/ 5ML ORAL SYRUP UD	250	RC	A9270	CPT				Both			6	2.7	0.01	33.88	0.01							Fee Schedule		4.44							Fee Schedule																				29.46							Fee Schedule		5.4							Fee Schedule		33.88							Fee Schedule		27.4							Fee Schedule											33.88							Fee Schedule		27.4							Fee Schedule		
PROMETHAZINE 12.5 MG /NS 50 ML IVPB	636	RC	J2550	CPT				Both			17.85	8.03	1.52	16.07		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	13.21							Fee Schedule		3.75							Fee Schedule		1.52							Fee Schedule											16.07							Fee Schedule																																															
PROMETHAZINE 12.5 MG RECTAL SUPPOSITORY	250	RC	A9270	CPT				Both			53.12	23.9	0.01	47.81	0.01							Fee Schedule		39.31							Fee Schedule																													47.81							Fee Schedule																																															
PROMETHAZINE 12.5 MG/NS25 ML PREMIX IVPB	636	RC	J2550	CPT				Both			11.55	5.2	1.52	10.4		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	8.55							Fee Schedule		3.75							Fee Schedule		1.52							Fee Schedule											10.4							Fee Schedule																																															
PROMETHAZINE 12.5MG (PHENERGAN) TABLET	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																				3.64							Fee Schedule		5.67							Fee Schedule		4.18							Fee Schedule		3.38							Fee Schedule											4.18							Fee Schedule		3.38							Fee Schedule		
PROMETHAZINE 12.5mg/10ml NS(SOLUSET/SYR)	250	RC	J2550	CPT				Both			17.85	8.03	1.52	16.07	2.06							Fee Schedule		13.21							Fee Schedule		3.75							Fee Schedule		1.52							Fee Schedule											16.07							Fee Schedule																																															
PROMETHAZINE 25 MG /NS 25 ML PREMIX IVPB	636	RC	J2550	CPT				Both			20.48	9.22	1.52	18.43		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	15.16							Fee Schedule		3.75							Fee Schedule		1.52							Fee Schedule		3.64							Fee Schedule		18.43							Fee Schedule		4.18							Fee Schedule		3.38							Fee Schedule											4.18							Fee Schedule		3.38							Fee Schedule		
PROMETHAZINE 25MG (PHENERGAN) TABLET	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
PROMETHAZINE 25MG/1.2ML TOPICAL OINT	250	RC	A9270	CPT				Both			17.85	8.03	0.01	16.07	0.01							Fee Schedule		13.21							Fee Schedule																				3.64							Fee Schedule		16.07							Fee Schedule		4.18							Fee Schedule		3.38							Fee Schedule											4.18							Fee Schedule		3.38							Fee Schedule		
PROMETHAZINE 25MG/ML (PHENERGAN) INJ	636	RC	J2550	CPT				Both			12.6	5.67	1.52	11.34		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	9.32							Fee Schedule		3.75							Fee Schedule		1.52							Fee Schedule		3.64							Fee Schedule		11.34							Fee Schedule		4.18							Fee Schedule		3.38							Fee Schedule											4.18							Fee Schedule		3.38							Fee Schedule		
PROMETHAZINE 25MG/NS 50ML IVPB	636	RC	J2550	CPT				Both			17.85	8.03	1.52	16.07		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	13.21							Fee Schedule		3.75							Fee Schedule		1.52							Fee Schedule											16.07							Fee Schedule																																															
PROMETHAZINE 50 MG/ML (PHENERGAN) INJ	636	RC	J2550	CPT				Both			11.55	5.2	1.52	10.4		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	8.55							Fee Schedule		3.75							Fee Schedule		1.52							Fee Schedule											10.4							Fee Schedule																																															
PROMETHAZINE 50MG/NS 50ML IVPB	636	RC	J2550	CPT				Both			144.9	65.21	1.52	130.41		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	107.23							Fee Schedule		3.75							Fee Schedule		1.52							Fee Schedule		3.64							Fee Schedule		130.41							Fee Schedule		4.18							Fee Schedule		3.38							Fee Schedule											4.18							Fee Schedule		3.38							Fee Schedule		
PROMETHAZINE 6276  4ML SERUM PHENERGAN	301	RC	80299	CPT				Both			145.95	65.68	3.38	131.36	13.42							Fee Schedule		18.64							Fee Schedule		19.2							Fee Schedule		18.64							Fee Schedule		3.64							Fee Schedule		131.36							Fee Schedule		4.18							Fee Schedule		3.38							Fee Schedule		18.64							Fee Schedule		4.18							Fee Schedule		3.38							Fee Schedule		
PROMETHAZINE WITH CODEINE SYRUP 5 ML UD	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																				3.64							Fee Schedule		5.67							Fee Schedule		4.18							Fee Schedule		3.38							Fee Schedule											4.18							Fee Schedule		3.38							Fee Schedule		
PROMETHAZINE WITH CODIENE SYRUP 5ML UD	250	RC	A9270	CPT				Both			5.25	2.36	0.01	4.73	0.01							Fee Schedule		3.89							Fee Schedule																				3.64							Fee Schedule		4.73							Fee Schedule		4.18							Fee Schedule		3.38							Fee Schedule											4.18							Fee Schedule		3.38							Fee Schedule		
PROMISE HEAVY YELLOW XL	272	RC	A4335	CPT				Both			1.8	0.81	0.81	21.44	1.17							Fee Schedule		1.33							Fee Schedule																				18.64							Fee Schedule		1.62							Fee Schedule		21.44							Fee Schedule		17.34							Fee Schedule											21.44							Fee Schedule		17.34							Fee Schedule		
PROMISE OVERNIGHT	272	RC	A4335	CPT				Both			44.1	19.85	19.85	39.69	28.67							Fee Schedule		32.63							Fee Schedule																													39.69							Fee Schedule																																															
PROMISE OVERNIGHT EACH YELLOW	272	RC	A4335	CPT				Both			2.42	1.09	1.09	2.18	1.57							Fee Schedule		1.79							Fee Schedule																													2.18							Fee Schedule																																															
PROMISE PANTIES 1PR	272	RC	A4335	CPT				Both			3.15	1.42	1.42	2.84	2.05							Fee Schedule		2.33							Fee Schedule																													2.84							Fee Schedule																																															
PROMISE STANDARD EACH BLUE	272	RC	A4335	CPT				Both			2	0.9	0.9	1.8	1.3							Fee Schedule		1.48							Fee Schedule																													1.8							Fee Schedule																																															
PROMISE STD	272	RC	A4335	CPT				Both			35.7	16.07	16.07	32.13	23.21							Fee Schedule		26.42							Fee Schedule																													32.13							Fee Schedule																																															
PROMOD PER SCOOP	250	RC						Both			4.2	1.89	1.89	3.78	2.73							Fee Schedule		3.11							Fee Schedule																													3.78							Fee Schedule																																															
PROMOGRAN PRISMA MATRIX 4.3 SQ MA028	272	RC	A6021	CPT				Both			25	11.25	11.25	30.87	18.93							Fee Schedule		18.5							Fee Schedule		30.87							Fee Schedule																				22.5							Fee Schedule																																															
PROMOGRAN PRISMA MATRIX ROPE #MA032	272	RC	A6024	CPT				Both			69	31.05	5.58	62.1	5.58							Fee Schedule		51.06							Fee Schedule		9.07							Fee Schedule																				62.1							Fee Schedule																																															
PROMOTE 240ML CAN	250	RC	B4150	CPT				Both			10.5	4.73	0.21	9.45	0.21							Fee Schedule		7.77							Fee Schedule											0.84							Fee Schedule											9.45							Fee Schedule																																															
PROMOTE WITH FIBER 240ML CAN	250	RC	B4150	CPT				Both			11.55	5.2	0.21	34.47	0.21							Fee Schedule		8.55							Fee Schedule											0.84							Fee Schedule		29.97							Fee Schedule		10.4							Fee Schedule		34.47							Fee Schedule		27.87							Fee Schedule											34.47							Fee Schedule		27.87							Fee Schedule		
PROMOTE/ FIBER READY TO HANG 1000 ML	250	RC	B4150	CPT				Both			52.64	23.69	0.21	47.38	0.21							Fee Schedule		38.95							Fee Schedule											0.84							Fee Schedule		8.81							Fee Schedule		47.38							Fee Schedule		10.13							Fee Schedule		8.19							Fee Schedule											10.13							Fee Schedule		8.19							Fee Schedule		
PRONE POSTIONER PILLOW PPD-30-106-RL-H	271	RC						Both			66	29.7	29.7	59.4	42.9							Fee Schedule		48.84							Fee Schedule																													59.4							Fee Schedule																																															
PROPAFENONE 150MG (RYTHMOL) TABLET	250	RC	A9270	CPT				Both			5.25	2.36	0.01	4.73	0.01							Fee Schedule		3.89							Fee Schedule																													4.73							Fee Schedule																																															
PROPOFOL 10 MG/ML- 100ML VIAL (DRIP)	250	RC	J2704	CPT				Both			118.65	53.39	0.09	106.79	0.1							Fee Schedule		87.8							Fee Schedule		0.09							Fee Schedule																				106.79							Fee Schedule																																															
PROPOFOL 10 MG/ML- 10ML SDV	250	RC						Both			22.05	9.92	9.92	19.85	14.33							Fee Schedule		16.32							Fee Schedule																													19.85							Fee Schedule																																															
PROPOFOL 10 MG/ML- 20 ML VIAL	250	RC	J2704	CPT				Both			23.1	10.4	0.09	20.79	0.1							Fee Schedule		17.09							Fee Schedule		0.09							Fee Schedule																				20.79							Fee Schedule																																															
PROPOFOL 10 MG/ML- 20ML VIAL	250	RC						Both			21.67	9.75	0.08	19.5	14.09							Fee Schedule		16.04							Fee Schedule																				0.09							Fee Schedule		19.5							Fee Schedule		0.1							Fee Schedule		0.08							Fee Schedule											0.1							Fee Schedule		0.08							Fee Schedule		
PROPOFOL 10 MG/ML- 50ML VIAL	250	RC	J2704	CPT				Both			58.8	26.46	0.09	52.92	0.1							Fee Schedule		43.51							Fee Schedule		0.09							Fee Schedule																				52.92							Fee Schedule																																															
PROPOXYPHENE 65 MG CAPSULE UD	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																				0.09							Fee Schedule		5.67							Fee Schedule		0.1							Fee Schedule		0.08							Fee Schedule											0.1							Fee Schedule		0.08							Fee Schedule		
PROPOXYPHENE NAPS/APAP 100-650 MG TABLET	250	RC	A9270	CPT				Both			5.25	2.36	0.01	4.73	0.01							Fee Schedule		3.89							Fee Schedule																													4.73							Fee Schedule																																															
PROPRANOLOL 1 MG/ML INJECTION	636	RC	J1800	CPT				Both			34.65	15.59	0.08	31.19		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	25.64							Fee Schedule											8.04							Fee Schedule		0.09							Fee Schedule		31.19							Fee Schedule		0.1							Fee Schedule		0.08							Fee Schedule											0.1							Fee Schedule		0.08							Fee Schedule		
PROPRANOLOL 10MG (INDERAL) TABLET	250	RC	A9270	CPT				Both			5.25	2.36	0.01	4.73	0.01							Fee Schedule		3.89							Fee Schedule																													4.73							Fee Schedule																																															
PROPRANOLOL 20MG (INDERAL) TABLET	250	RC	A9270	CPT				Both			5.25	2.36	0.01	4.73	0.01							Fee Schedule		3.89							Fee Schedule																													4.73							Fee Schedule																																															
PROPRANOLOL LA 80MG (INDERAL LA) CAPSULE	250	RC	A9270	CPT				Both			5.25	2.36	0.01	4.73	0.01							Fee Schedule		3.89							Fee Schedule																													4.73							Fee Schedule																																															
PROPULSID:10 MG (CISAPRIDE) TAB	250	RC	A9270	CPT				Both			1.97	0.89	0.01	1.77	0.01							Fee Schedule		1.46							Fee Schedule																													1.77							Fee Schedule																																															
PROPYLTHIOURACIL 50 MG TABLET	250	RC	A9270	CPT				Both			5.25	2.36	0.01	4.73	0.01							Fee Schedule		3.89							Fee Schedule																													4.73							Fee Schedule																																															
PROQUAD (MMR AND VARICELLA) VACCINE	636	RC	90710	CPT				Both			308.7	138.92	131.24	277.83		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	228.44							Fee Schedule											131.24							Fee Schedule											277.83							Fee Schedule																																															
PROSOM 2 MG TABLET	250	RC	A9270	CPT				Both			2.45	1.1	0.01	2.21	0.01							Fee Schedule		1.81							Fee Schedule																													2.21							Fee Schedule																																															
PROSTAGLANDIN E2  91901 SERUM 3ML	301	RC	84150	CPT				Both			330.75	148.84	30.07	297.68	30.07							Fee Schedule		41.77							Fee Schedule		43.02							Fee Schedule		41.77							Fee Schedule											297.68							Fee Schedule																				41.77							Fee Schedule																				
PROSTAPHLIN : 1GM ADV (OXACILLIN)	636	RC	J2700	CPT				Both			66.65	29.99	0.79	59.99		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	49.32							Fee Schedule		0.79							Fee Schedule		1.83							Fee Schedule											59.99							Fee Schedule																																															
PROSTAPHLIN 1 GM VIAL   (OXACILLIN)	636	RC	J2700	CPT				Both			11.55	5.2	0.79	10.4		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	8.55							Fee Schedule		0.79							Fee Schedule		1.83							Fee Schedule											10.4							Fee Schedule																																															
PROSTATE BIOPSY NEEDLE	254	RC						Both			224.7	101.12	38.85	202.23	146.06							Fee Schedule		166.28							Fee Schedule																				41.77							Fee Schedule		202.23							Fee Schedule		48.04							Fee Schedule		38.85							Fee Schedule											48.04							Fee Schedule		38.85							Fee Schedule		
POSTPARTUM AND POST ABORTION DIAGNOSES WITH O.R. PROCEDURES					769	DRG		Inpatient			19653.41	8844.03	8844.03	8844.03							0		No services performed during 15 month lookback period. 				1866.1	1866.1	1866.1	1 through 10									0		No services performed during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0	Fee Schedule	No services provided during 15 month lookback period							0	Fee Schedule	No services provided during 15 month lookback period							0		No services provided during 15 month lookback							0		No services provided during 15 month lookback period							0	Fee Schedule	No services provided during 15 month lookback period	
PROSTIGMIN 1:2000 MDV	636	RC	J2710	CPT				Both			20.7	9.32	0.71	18.63		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	15.32							Fee Schedule											0.88							Fee Schedule		0.76							Fee Schedule		18.63							Fee Schedule		0.88							Fee Schedule		0.71							Fee Schedule											0.88							Fee Schedule		0.71							Fee Schedule		
PROSTIGMIN 5CC	250	RC						Both			15.75	7.09	7.09	14.18	10.24							Fee Schedule		11.66							Fee Schedule																													14.18							Fee Schedule																																															
PROSTIN E-2 VAGINAL SUPPOSITORY	636	RC						Both			1753.5	789.08	789.08	1578.15		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1297.59							Fee Schedule																													1578.15							Fee Schedule																																															
PROT + GUIDE PLUS480	272	RC						Both			330.75	148.84	148.84	297.68	214.99							Fee Schedule		244.76							Fee Schedule																													297.68							Fee Schedule																																															
PROTAMINE 10 MG/ML-25ML VIAL	636	RC	J2720	CPT				Both			110.25	49.61	1.07	99.23		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	81.59							Fee Schedule		1.82							Fee Schedule		1.07							Fee Schedule											99.23							Fee Schedule																																															
PROTAMINE SULFATE 50MG/NS 50ML	250	RC	J2720	CPT				Both			36.75	16.54	1.07	33.08	1.09							Fee Schedule		27.2							Fee Schedule		1.82							Fee Schedule		1.07							Fee Schedule											33.08							Fee Schedule																																															
PROTEIN / CREATININE WITH RATIO URINE	301	RC	84156	CPT				Both			23.1	10.4	3.26	20.79	3.26							Fee Schedule		4.07							Fee Schedule		3.78							Fee Schedule		3.67							Fee Schedule											20.79							Fee Schedule																				3.67							Fee Schedule																				
PROTEIN C ACTIVITY 1777	305	RC	85303	CPT				Both			309.75	139.39	1.64	278.78	12.3							Fee Schedule		15.37							Fee Schedule		14.26							Fee Schedule		13.84							Fee Schedule		1.77							Fee Schedule		278.78							Fee Schedule		2.03							Fee Schedule		1.64							Fee Schedule		13.84							Fee Schedule		2.03							Fee Schedule		1.64							Fee Schedule		
PROTEIN C ANTIGEN 4948	305	RC	85302	CPT				Both			68.25	30.71	1.64	61.43	10.68							Fee Schedule		13.35							Fee Schedule		12.37							Fee Schedule		12.01							Fee Schedule		1.77							Fee Schedule		61.43							Fee Schedule		2.03							Fee Schedule		1.64							Fee Schedule		12.01							Fee Schedule		2.03							Fee Schedule		1.64							Fee Schedule		
PROTEIN CREAT RATIO 1715 10 ML URINE	301	RC	84156	CPT				Both			39.9	17.96	3.26	35.91	3.26							Fee Schedule		4.07							Fee Schedule		3.78							Fee Schedule		3.67							Fee Schedule		3.67							Fee Schedule		35.91							Fee Schedule		4.22							Fee Schedule		3.41							Fee Schedule		3.67							Fee Schedule		4.22							Fee Schedule		3.41							Fee Schedule		
PROTEIN CSF	301	RC	84157	CPT				Both			23.1	10.4	3.26	20.79	3.26							Fee Schedule		4.07							Fee Schedule		4.12							Fee Schedule		4							Fee Schedule		13.84							Fee Schedule		20.79							Fee Schedule		15.92							Fee Schedule		12.87							Fee Schedule		4							Fee Schedule		15.92							Fee Schedule		12.87							Fee Schedule		
PROTEIN ELECTRO UR 24HR 750	301	RC	84166	CPT				Both			99.75	44.89	11.17	89.78	15.85							Fee Schedule		19.81							Fee Schedule		18.36							Fee Schedule		17.83							Fee Schedule		12.01							Fee Schedule		89.78							Fee Schedule		13.81							Fee Schedule		11.17							Fee Schedule		17.83							Fee Schedule		13.81							Fee Schedule		11.17							Fee Schedule		
PROTEIN ELECTRO UR RANDOM 8525 15 ML URI	301	RC	84166	CPT				Both			99.75	44.89	3.41	89.78	15.85							Fee Schedule		19.81							Fee Schedule		18.36							Fee Schedule		17.83							Fee Schedule		3.67							Fee Schedule		89.78							Fee Schedule		4.22							Fee Schedule		3.41							Fee Schedule		17.83							Fee Schedule		4.22							Fee Schedule		3.41							Fee Schedule		
PROTEIN ELECTROPHRESIS 749 CSF	301	RC	84166	CPT				Both			120.75	54.34	3.72	108.68	15.85							Fee Schedule		19.81							Fee Schedule		18.36							Fee Schedule		17.83							Fee Schedule		4							Fee Schedule		108.68							Fee Schedule		4.6							Fee Schedule		3.72							Fee Schedule		17.83							Fee Schedule		4.6							Fee Schedule		3.72							Fee Schedule		
PROTEIN FLUID 1ML FLUID	301	RC	84157	CPT				Both			29.4	13.23	3.26	26.46	3.26							Fee Schedule		4.07							Fee Schedule		4.12							Fee Schedule		4							Fee Schedule		17.83							Fee Schedule		26.46							Fee Schedule		20.5							Fee Schedule		16.58							Fee Schedule		4							Fee Schedule		20.5							Fee Schedule		16.58							Fee Schedule		
PROTEIN IMMUNOELECT SERUM  549 SERUM	302	RC	86320	CPT				Both			140.7	63.32	16.58	126.63	21.54							Fee Schedule		29.92							Fee Schedule		30.82							Fee Schedule		29.92							Fee Schedule		17.83							Fee Schedule		126.63							Fee Schedule		20.5							Fee Schedule		16.58							Fee Schedule		29.92							Fee Schedule		20.5							Fee Schedule		16.58							Fee Schedule		
PROTEIN S ACTIVITY 1779	305	RC	85306	CPT				Both			325.5	146.48	13.62	292.95	13.62							Fee Schedule		17.03							Fee Schedule		15.78							Fee Schedule		15.32							Fee Schedule		17.83							Fee Schedule		292.95							Fee Schedule		20.5							Fee Schedule		16.58							Fee Schedule		15.32							Fee Schedule		20.5							Fee Schedule		16.58							Fee Schedule		
PROTEIN S ANTIGEN 5165	305	RC	85305	CPT				Both			155.4	69.93	3.72	139.86	10.32							Fee Schedule		12.9							Fee Schedule		11.96							Fee Schedule		11.61							Fee Schedule		4							Fee Schedule		139.86							Fee Schedule		4.6							Fee Schedule		3.72							Fee Schedule		11.61							Fee Schedule		4.6							Fee Schedule		3.72							Fee Schedule		
PROTEIN TOT & ELECTROPHORESIS 747	301	RC	84165	CPT				Both			69.3	31.19	9.55	62.37	9.55							Fee Schedule		11.93							Fee Schedule		11.06							Fee Schedule		10.74							Fee Schedule		29.92							Fee Schedule		62.37							Fee Schedule		34.41							Fee Schedule		27.83							Fee Schedule		10.74							Fee Schedule		34.41							Fee Schedule		27.83							Fee Schedule		
PROTEIN UR RANDOM	301	RC	84156	CPT				Both			23.1	10.4	3.26	20.79	3.26							Fee Schedule		4.07							Fee Schedule		3.78							Fee Schedule		3.67							Fee Schedule		15.32							Fee Schedule		20.79							Fee Schedule		17.62							Fee Schedule		14.25							Fee Schedule		3.67							Fee Schedule		17.62							Fee Schedule		14.25							Fee Schedule		
PROTEIN URINE 24 HR	301	RC	84156	CPT				Both			45.15	20.32	3.26	40.64	3.26							Fee Schedule		4.07							Fee Schedule		3.78							Fee Schedule		3.67							Fee Schedule		11.61							Fee Schedule		40.64							Fee Schedule		13.35							Fee Schedule		10.8							Fee Schedule		3.67							Fee Schedule		13.35							Fee Schedule		10.8							Fee Schedule		
"PROTEIN, TOTAL, PERITONEAL FLD 17428"	301	RC	84157	CPT				Both			21	9.45	3.26	18.9	3.26							Fee Schedule		4.07							Fee Schedule		4.12							Fee Schedule		4							Fee Schedule		10.74							Fee Schedule		18.9							Fee Schedule		12.35							Fee Schedule		9.99							Fee Schedule		4							Fee Schedule		12.35							Fee Schedule		9.99							Fee Schedule		
PROTHROMBIN FACTOR II  MUTATION 17909	310	RC	81240	CPT				Both			475.65	214.04	3.41	428.09	47.3							Fee Schedule		65.69							Fee Schedule		67.66							Fee Schedule		65.69							Fee Schedule		3.67							Fee Schedule		428.09							Fee Schedule		4.22							Fee Schedule		3.41							Fee Schedule											4.22							Fee Schedule		3.41							Fee Schedule		
PROTIME	305	RC	85610	CPT				Both			102.9	46.31	3.41	92.61	3.49							Fee Schedule		4.37							Fee Schedule		4.42							Fee Schedule		4.29							Fee Schedule		3.67							Fee Schedule		92.61							Fee Schedule		4.22							Fee Schedule		3.41							Fee Schedule		4.29							Fee Schedule		4.22							Fee Schedule		3.41							Fee Schedule		
PROTONIX 40 MG (PANTOPRAZOLE ) IVPB	250	RC						Both			18.9	8.51	3.72	17.01	12.29							Fee Schedule		13.99							Fee Schedule																				4							Fee Schedule		17.01							Fee Schedule		4.6							Fee Schedule		3.72							Fee Schedule											4.6							Fee Schedule		3.72							Fee Schedule		
PROTONIX 40 MG (PANTOPRAZOLE) TABLET	250	RC	A9270	CPT				Both			6.3	2.84	0.01	75.54	0.01							Fee Schedule		4.66							Fee Schedule																				65.69							Fee Schedule		5.67							Fee Schedule		75.54							Fee Schedule		61.09							Fee Schedule											75.54							Fee Schedule		61.09							Fee Schedule		
PROTONIX 40 MG (PANTOPRAZOLE) VIAL	250	RC	J2470	CPT				Both			18.9	8.51	3.99	17.01	12.29							Fee Schedule		13.99							Fee Schedule																				4.29							Fee Schedule		17.01							Fee Schedule		4.93							Fee Schedule		3.99							Fee Schedule											4.93							Fee Schedule		3.99							Fee Schedule		
PROTONIX 40 MG ORAL SUSP	250	RC	A9270	CPT				Both			4.79	2.16	0.01	4.31	0.01							Fee Schedule		3.54							Fee Schedule																													4.31							Fee Schedule																																															
PROTONIX 80MG/NS 100ML IVPB	250	RC	J2470	CPT				Both			45.15	20.32	20.32	40.64	29.35							Fee Schedule		33.41							Fee Schedule																													40.64							Fee Schedule																																															
PROTOPORPHYRIN RBC 762	301	RC	84202	CPT				Both			90.3	40.64	12.75	81.27	12.75							Fee Schedule		15.94							Fee Schedule		14.78							Fee Schedule		14.35							Fee Schedule											81.27							Fee Schedule																				14.35							Fee Schedule																				
PROVENTIL HFA INHALER	636	RC	J3535	CPT				Both			82.72	37.22	37.22	74.45		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	61.21							Fee Schedule																													74.45							Fee Schedule																																															
PROVENTIL W/ATROVENT (RT) -DUONEB	250	RC						Both			7.35	3.31	3.31	6.62	4.78							Fee Schedule		5.44							Fee Schedule																													6.62							Fee Schedule																																															
PROVENTIL:2 MG TAB	250	RC	A9270	CPT				Both			1.58	0.71	0.01	16.5	0.01							Fee Schedule		1.17							Fee Schedule																				14.35							Fee Schedule		1.42							Fee Schedule		16.5							Fee Schedule		13.35							Fee Schedule											16.5							Fee Schedule		13.35							Fee Schedule		
PROVENTYL 1GM	250	RC						Both			4.2	1.89	1.89	3.78	2.73							Fee Schedule		3.11							Fee Schedule																													3.78							Fee Schedule																																															
PROVERA 2.5 MG TABS	250	RC	A9270	CPT				Both			1.58	0.71	0.01	1.42	0.01							Fee Schedule		1.17							Fee Schedule																													1.42							Fee Schedule																																															
PROVOCHOLINE (METHACHOLINE) 100 MG VIAL	250	RC	J7674	CPT				Both			283.5	127.58	0.75	255.15	0.75							Fee Schedule		209.79							Fee Schedule		2							Fee Schedule																				255.15							Fee Schedule																																															
PROZAC 90 MG CAPSULE WEEKLY	250	RC	A9270	CPT				Both			59.54	26.79	0.01	53.59	0.01							Fee Schedule		44.06							Fee Schedule																													53.59							Fee Schedule																																															
"PRSS1 GENE, FULL ANALYSIS 93163"	300	RC	81404	CPT				Both			2151	967.95	197.88	1935.9	197.88							Fee Schedule		274.83							Fee Schedule		283.07							Fee Schedule		274.83							Fee Schedule											1935.9							Fee Schedule																				274.83							Fee Schedule																				
PSA  NOT SCREENING	301	RC	84153	CPT				Both			100.8	45.36	1.81	90.72	16.35							Fee Schedule		20.44							Fee Schedule		18.94							Fee Schedule		18.39							Fee Schedule		1.94							Fee Schedule		90.72							Fee Schedule		2.23							Fee Schedule		1.81							Fee Schedule		18.39							Fee Schedule		2.23							Fee Schedule		1.81							Fee Schedule		
PSA FREE 31348 1 ML SERUM FROZEN	301	RC	84154	CPT				Both			99.75	44.89	16.35	89.78	16.35							Fee Schedule		20.44							Fee Schedule		18.94							Fee Schedule		18.39							Fee Schedule											89.78							Fee Schedule																				18.39							Fee Schedule																				
PSA SCREENING 1 PER YR AGE >50	301	RC	84153	CPT				Both			99.75	44.89	16.35	316.05	16.35							Fee Schedule		20.44							Fee Schedule		18.94							Fee Schedule		18.39							Fee Schedule		274.83							Fee Schedule		89.78							Fee Schedule		316.05							Fee Schedule		255.59							Fee Schedule		18.39							Fee Schedule		316.05							Fee Schedule		255.59							Fee Schedule		
PSE/GUIAFEN 50-1200 MG SR TABLET UD	250	RC	A9270	CPT				Both			4.2	1.89	0.01	21.15	0.01							Fee Schedule		3.11							Fee Schedule																				18.39							Fee Schedule		3.78							Fee Schedule		21.15							Fee Schedule		17.1							Fee Schedule											21.15							Fee Schedule		17.1							Fee Schedule		
POSTPARTUM AND POST ABORTION DIAGNOSES WITHOUT O.R. PROCEDUR					776	DRG		Inpatient			15806.45	7112.9	7112.9	7112.9							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period				1654.14	1654.14	1654.14	1 through 10									0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0	Fee Schedule	No services provided during 15 month lookback period							0	Fee Schedule	No services provided during 15 month lookback period							0		No services provided during 15 month lookback							0		No services provided during 15 month lookback period							0	Fee Schedule	No services provided during 15 month lookback period	
PT	305	RC	85610	CPT				Both			102.9	46.31	3.49	92.61	3.49							Fee Schedule		4.37							Fee Schedule		4.42							Fee Schedule		4.29							Fee Schedule		18.39							Fee Schedule		92.61							Fee Schedule		21.15							Fee Schedule		17.1							Fee Schedule		4.29							Fee Schedule		21.15							Fee Schedule		17.1							Fee Schedule		
PT EVAL HIGH 45 MIN	424	RC	97163	CPT				Both			315	141.75	66.74	318	200							Per Diem		233.1							Fee Schedule											66.74							Fee Schedule											283.5							Fee Schedule																				318							Per Diem																				
PT EVAL LOW COMPLEX 20 MIN	424	RC	97161	CPT				Both			315	141.75	66.74	318	200							Per Diem		233.1							Fee Schedule											66.74							Fee Schedule											283.5							Fee Schedule																				318							Per Diem																				
PT EVAL MOD 30 MIN	424	RC	97162	CPT				Both			315	141.75	3.99	318	200							Per Diem		233.1							Fee Schedule											66.74							Fee Schedule		4.29							Fee Schedule		283.5							Fee Schedule		4.93							Fee Schedule		3.99							Fee Schedule		318							Per Diem		4.93							Fee Schedule		3.99							Fee Schedule		
PT REEVAL EST PLAN CARE	424	RC	97164	CPT				Both			315	141.75	45.14	318	200							Per Diem		233.1							Fee Schedule											45.14							Fee Schedule											283.5							Fee Schedule																				318							Per Diem																				
PT WORK CONDITIONING 2 HRS	422	RC	97545	CPT				Both			488.25	219.71	200	439.43	200							Per Diem		361.31							Fee Schedule																													439.43							Fee Schedule																				318							Per Diem																				
PT WOUND CARE	420	RC	97597	CPT				Both			315	141.75	39.59	318	200							Per Diem		233.1							Fee Schedule											39.59							Fee Schedule											283.5							Fee Schedule																				318							Per Diem																				
PTA WORK CONDITIONING 2 H	422	RC	97545	CPT				Both			488.25	219.71	200	439.43	200							Per Diem		361.31							Fee Schedule																													439.43							Fee Schedule																				318							Per Diem																				
PTA WOUND CARE	420	RC	97597	CPT				Both			315	141.75	39.59	318	200							Per Diem		233.1							Fee Schedule											39.59							Fee Schedule											283.5							Fee Schedule																				318							Per Diem																				
PTFE DLEDGETS 007963 PERIPH	272	RC						Both			4.2	1.89	1.89	3.78	2.73							Fee Schedule		3.11							Fee Schedule																													3.78							Fee Schedule																																															
PTH RELATED PROTEIN 34478 PTH TUBE  RT	301	RC	83519	CPT				Both			358.05	161.12	13.25	322.25	13.25							Fee Schedule		18.4							Fee Schedule		18.95							Fee Schedule		18.4							Fee Schedule											322.25							Fee Schedule																				18.4							Fee Schedule																				
PTR15 SKIN STAPLES	272	RC						Both			55.65	25.04	25.04	50.09	36.17							Fee Schedule		41.18							Fee Schedule																													50.09							Fee Schedule																																															
PTT	305	RC	85730	CPT				Both			102.9	46.31	5.34	92.61	5.34							Fee Schedule		6.67							Fee Schedule		6.19							Fee Schedule		6.01							Fee Schedule											92.61							Fee Schedule																				6.01							Fee Schedule																				
PUDENDAL KIT SAFETY BD# 402601	272	RC						Both			49.35	22.21	17.11	44.42	32.08							Fee Schedule		36.52							Fee Schedule																				18.4							Fee Schedule		44.42							Fee Schedule		21.16							Fee Schedule		17.11							Fee Schedule											21.16							Fee Schedule		17.11							Fee Schedule		
PULL TIGHT SEAL RED 7821	270	RC						Both			0.88	0.4	0.4	0.79	0.57							Fee Schedule		0.65							Fee Schedule																													0.79							Fee Schedule																																															
PULL TIGHT SEAL YELLOW 7823	270	RC						Both			0.88	0.4	0.4	6.91	0.57							Fee Schedule		0.65							Fee Schedule																				6.01							Fee Schedule		0.79							Fee Schedule		6.91							Fee Schedule		5.59							Fee Schedule											6.91							Fee Schedule		5.59							Fee Schedule		
PULLEY  564390	270	RC						Both			46	20.7	20.7	41.4	29.9							Fee Schedule		34.04							Fee Schedule																													41.4							Fee Schedule																																															
PULLEY 564390	270	RC						Both			41	18.45	18.45	36.9	26.65							Fee Schedule		30.34							Fee Schedule																													36.9							Fee Schedule																																															
PULLEY WITH DOOR STRAP 081411016	270	RC						Both			33	14.85	14.85	29.7	21.45							Fee Schedule		24.42							Fee Schedule																													29.7							Fee Schedule																																															
PULMICORT 180MCG FLEXHALER	636	RC	J3535	CPT				Both			456.21	205.29	205.29	410.59		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	337.6							Fee Schedule																													410.59							Fee Schedule																																															
PULMICORT 90 MCG FLEXHALER	636	RC	J3535	CPT				Both			375.61	169.02	169.02	338.05		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	277.95							Fee Schedule																													338.05							Fee Schedule																																															
PULMICORT RESPULES 0.25MG/2ML UD (RT)	250	RC	J7626	CPT				Both			32.55	14.65	1.12	29.3	1.74							Fee Schedule		24.09							Fee Schedule		1.12							Fee Schedule																				29.3							Fee Schedule																																															
PULMICORT RESPULES 0.5MG/2ML UD (RT)	250	RC	J7626	CPT				Both			38.85	17.48	1.12	34.97	1.74							Fee Schedule		28.75							Fee Schedule		1.12							Fee Schedule																				34.97							Fee Schedule																																															
PULMO. FUNC. MOUTH PC. DISP	271	RC						Both			7.35	3.31	3.31	6.62	4.78							Fee Schedule		5.44							Fee Schedule																													6.62							Fee Schedule																																															
PULMOCARE 1.5 CAL 1000 ML	250	RC						Both			45.15	20.32	1.02	40.64	29.35							Fee Schedule		33.41							Fee Schedule																				1.09							Fee Schedule		40.64							Fee Schedule		1.26							Fee Schedule		1.02							Fee Schedule											1.26							Fee Schedule		1.02							Fee Schedule		
PULMOCARE 240ML CAN	250	RC						Both			7.35	3.31	1.02	6.62	4.78							Fee Schedule		5.44							Fee Schedule																				1.09							Fee Schedule		6.62							Fee Schedule		1.26							Fee Schedule		1.02							Fee Schedule											1.26							Fee Schedule		1.02							Fee Schedule		
CESAREAN SECTION WITH STERILIZATION WITH CC					784	DRG		Inpatient			23463.05	10558.37	10558.37	10558.37							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period				5297.98	5297.98	5297.98	1 through 10									0		No services provided during 15 month lookback							0		No services provided during 15 month lookback period				5506.38	5506.38	5506.38	1 through 10			
CESAREAN SECTION WITH STERILIZATION WITHOUT CC/MCC					785	DRG		Inpatient			21062.52	9478.13	9478.13	9478.13							0		No services performed during 15 month lookback period. 				547.48	547.48	547.4	1 through 10									0		No services performed during 15 month lookback period				3883.9	3883.9	3883.9	1 through 10									0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period				4453.72	4453.72	4453.72	1 through 10									0		No services provided during 15 month lookback							0		No services provided during 15 month lookback period				1092	1092	1092	1 through 10			
CESAREAN SECTION WITHOUT STERILIZATION WITH MCC					786	DRG		Inpatient			30071.88	13532.35	13532.35	13532.35							0		No services performed during 15 month lookback period. 				1108.58	1108.58	1108.58	1 through 10									0		No services performed during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period	
PUMICE STONE	250	RC						Both			7.35	3.31	3.31	6.62	4.78							Fee Schedule		5.44							Fee Schedule																													6.62							Fee Schedule																																															
PUNCH BIOPSY #1 MILTEX 33-31AA	272	RC						Both			10.5	4.73	4.73	9.45	6.83							Fee Schedule		7.77							Fee Schedule																													9.45							Fee Schedule																																															
PUNCH BIOPSY #2 MILTEX 33-31	272	RC						Both			10.5	4.73	4.73	9.45	6.83							Fee Schedule		7.77							Fee Schedule																													9.45							Fee Schedule																																															
PUNCH BIOPSY #3 MILTEX 33-32	272	RC						Both			3.8	1.71	1.71	3.42	2.47							Fee Schedule		2.81							Fee Schedule																													3.42							Fee Schedule																																															
PUNCH BIOPSY #4 MILTEX 33-34	272	RC						Both			3.8	1.71	1.71	3.42	2.47							Fee Schedule		2.81							Fee Schedule																													3.42							Fee Schedule																																															
PUNCH BIOPSY #5 MILTEX 33-35	272	RC						Both			3.8	1.71	1.71	3.42	2.47							Fee Schedule		2.81							Fee Schedule																													3.42							Fee Schedule																																															
PUNCH BIOPSY #6 MILTEX 33-36	272	RC						Both			7	3.15	3.15	6.3	4.55							Fee Schedule		5.18							Fee Schedule																													6.3							Fee Schedule																																															
PUNCH BIOPSY #8 MILTEX 33-37	272	RC						Both			3.8	1.71	1.71	3.42	2.47							Fee Schedule		2.81							Fee Schedule																													3.42							Fee Schedule																																															
PURACOL COLLAGEN DSG. 4X4.25 #MSC8544	272	RC	A6022	CPT				Both			18	8.1	8.1	30.87	18.93							Fee Schedule		13.32							Fee Schedule		30.87							Fee Schedule																				16.2							Fee Schedule																																															
PURASTAT 3ML SYRINGE 621-062  3-D MATRIX	272	RC	C1052	CPT				Both			2250	1012.5	1012.5	2025	1462.5							Fee Schedule		1665							Fee Schedule																													2025							Fee Schedule																																															
PURASTAT ADAPTER 001-099  (3-D MATRIX)	272	RC						Both			75	33.75	33.75	67.5	48.75							Fee Schedule		55.5							Fee Schedule																													67.5							Fee Schedule																																															
PURASTAT CATHETER WP-18/2200 3D MATRIX	272	RC						Both			42	18.9	18.9	37.8	27.3							Fee Schedule		31.08							Fee Schedule																				29.97							Fee Schedule		37.8							Fee Schedule		34.47							Fee Schedule		27.87							Fee Schedule											34.47							Fee Schedule		27.87							Fee Schedule		
PUREWICK FEMALE EXTERNAL CATH #PWF030K	270	RC	A6590	CPT				Both			25	11.25	11.25	433.84	16.25							Fee Schedule		18.5							Fee Schedule		433.84							Fee Schedule																				22.5							Fee Schedule																																															
PUREWICK MALE EXTERNAL CATH #PWM030	270	RC	A6590	CPT				Both			49	22.05	22.05	433.84	31.85							Fee Schedule		36.26							Fee Schedule		433.84							Fee Schedule																				44.1							Fee Schedule																																															
PURKINJE CELL (YO) ANTIBODY 37360 SERUM	302	RC	86255	CPT				Both			178.5	80.33	10.71	160.65	10.71							Fee Schedule		13.39							Fee Schedule		12.41							Fee Schedule		12.05							Fee Schedule											160.65							Fee Schedule																				12.05							Fee Schedule																				
PUSHING CATHETER 7FR FS-PC-7	272	RC						Both			189	85.05	85.05	484.38	122.85							Fee Schedule		139.86							Fee Schedule																				421.2							Fee Schedule		170.1							Fee Schedule		484.38							Fee Schedule		391.72							Fee Schedule											484.38							Fee Schedule		391.72							Fee Schedule		
PUTTY BLUE	271	RC						Both			8.66	3.9	3.9	484.38	5.63							Fee Schedule		6.41							Fee Schedule																				421.2							Fee Schedule		7.79							Fee Schedule		484.38							Fee Schedule		391.72							Fee Schedule											484.38							Fee Schedule		391.72							Fee Schedule		
PUTTY GREEN	271	RC						Both			8.66	3.9	3.9	13.86	5.63							Fee Schedule		6.41							Fee Schedule																				12.05							Fee Schedule		7.79							Fee Schedule		13.86							Fee Schedule		11.21							Fee Schedule											13.86							Fee Schedule		11.21							Fee Schedule		
PUTTY RED 3OZ 929912	271	RC						Both			8	3.6	3.6	7.2	5.2							Fee Schedule		5.92							Fee Schedule																													7.2							Fee Schedule																																															
PUTTY YELLOW 3OZ 929911	271	RC						Both			8	3.6	3.6	7.2	5.2							Fee Schedule		5.92							Fee Schedule																													7.2							Fee Schedule																																															
PYLORIC TTS DIALATOR	272	RC	C1726	CPT				Both			731.85	329.33	135.94	658.67	135.94							Fee Schedule		541.57							Fee Schedule																													658.67							Fee Schedule																																															
PYRAZINAMIDE 500 MG TABLET UD	250	RC	A9270	CPT				Both			4.2	1.89	0.01	3.78	0.01							Fee Schedule		3.11							Fee Schedule																													3.78							Fee Schedule																																															
PYRIDIUM 200 MG TABS	250	RC	A9270	CPT				Both			1.58	0.71	0.01	1.42	0.01							Fee Schedule		1.17							Fee Schedule																													1.42							Fee Schedule																																															
PYRIDOXINE 100 MG/ML INJECTION	636	RC	J3415	CPT				Both			19.95	8.98	8.98	17.96		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	14.76							Fee Schedule		13.33							Fee Schedule																				17.96							Fee Schedule																																															
PYRIDOXINE 100MG/ML INJ-1ML	636	RC	J3420	CPT				Both			63	28.35	0.3	56.7		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	46.62							Fee Schedule		0.7							Fee Schedule		0.3							Fee Schedule											56.7							Fee Schedule																																															
PYRIDOXINE VIT B6  926 PROTECT LIGHT FZ	301	RC	84207	CPT				Both			233.1	104.9	24.98	209.79	24.98							Fee Schedule		31.22							Fee Schedule		28.94							Fee Schedule		28.1							Fee Schedule											209.79							Fee Schedule																				28.1							Fee Schedule																				
PYRUVATE KINASE  39855	301	RC	84220	CPT				Both			176.8	79.56	8.4	159.12	8.4							Fee Schedule		10.49							Fee Schedule		9.72							Fee Schedule		9.44							Fee Schedule		12.94							Fee Schedule		159.12							Fee Schedule		14.88							Fee Schedule		12.04							Fee Schedule		9.44							Fee Schedule		14.88							Fee Schedule		12.04							Fee Schedule		
Q50X STENT BALLOON CATHETER Q50-100-X	272	RC	C1725	CPT				Both			2516.85	1132.58	0.64	2265.17	93.3							Fee Schedule		1862.47							Fee Schedule																				0.68							Fee Schedule		2265.17							Fee Schedule		0.79							Fee Schedule		0.64							Fee Schedule											0.79							Fee Schedule		0.64							Fee Schedule		
Q-FIX  SUTURE ANCHOR 25-1810	278	RC	C1713	CPT				Both			525	236.25	26.13	472.5		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	388.5							Fee Schedule																				28.1							Fee Schedule		472.5							Fee Schedule		32.32							Fee Schedule		26.13							Fee Schedule											32.32							Fee Schedule		26.13							Fee Schedule		
Q-FIX KNOTLESS SUTURE ANCHOR 72205882	278	RC	C1713	CPT				Both			5406	2432.7	8.78	4865.4		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	4000.44							Fee Schedule																				9.44							Fee Schedule		4865.4							Fee Schedule		10.86							Fee Schedule		8.78							Fee Schedule											10.86							Fee Schedule		8.78							Fee Schedule		
Q-FIX KNOTLESS SUTURE ANCHOR 72205883	278	RC	C1713	CPT				Both			1350	607.5	607.5	1215		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	999							Fee Schedule																													1215							Fee Schedule																																															
Q-FIX KNOTLESS SUTURE ANCHOR 72205885	278	RC	C1713	CPT				Both			1350	607.5	607.5	1215		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	999							Fee Schedule																													1215							Fee Schedule																																															
Q-FIX SUTURE ANCHOR 72205859	278	RC	C1713	CPT				Both			1350	607.5	607.5	1215		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	999							Fee Schedule																													1215							Fee Schedule																																															
QHERIT  COLLECTION CHARGE  94372	300	RC	36415	CPT				Both			20	9	2.16	18	2.16							Fee Schedule		3							Fee Schedule		9.62							Fee Schedule		8.83							Fee Schedule											18							Fee Schedule																				8.83							Fee Schedule																				
QNATAL COLLECTION CHARGE  92777	300	RC	36415	CPT				Both			20	9	2.16	18	2.16							Fee Schedule		3							Fee Schedule		9.62							Fee Schedule		8.83							Fee Schedule											18							Fee Schedule																				8.83							Fee Schedule																				
QUAD LUMEN ECVC895( TRISTATE ) SAFETY	272	RC	A4300	CPT				Both			357	160.65	4.57	321.3	17.2							Fee Schedule		264.18							Fee Schedule											4.57							Fee Schedule											321.3							Fee Schedule																																															
QUANTIFERON TB 36970	302	RC	86480	CPT				Both			336	151.2	8.69	302.4	55.09							Fee Schedule		68.87							Fee Schedule		63.84							Fee Schedule		61.98							Fee Schedule		9.34							Fee Schedule		302.4							Fee Schedule		10.74							Fee Schedule		8.69							Fee Schedule		61.98							Fee Schedule		10.74							Fee Schedule		8.69							Fee Schedule		
QUANTIFERON TB GOLD 36971 SP DRAW 4TUBES	302	RC	86480	CPT				Both			336	151.2	8.69	302.4	55.09							Fee Schedule		68.87							Fee Schedule		63.84							Fee Schedule		61.98							Fee Schedule		9.34							Fee Schedule		302.4							Fee Schedule		10.74							Fee Schedule		8.69							Fee Schedule		61.98							Fee Schedule		10.74							Fee Schedule		8.69							Fee Schedule		
QUESTRAN LITE     (CHOLESTYRAMINE)	250	RC	A9270	CPT				Both			7.35	3.31	0.01	6.62	0.01							Fee Schedule		5.44							Fee Schedule																													6.62							Fee Schedule																																															
QUETIAPINE   25MG (SEROQUEL ) TABLET	250	RC	A9270	CPT				Both			6.3	2.84	0.01	71.28	0.01							Fee Schedule		4.66							Fee Schedule																				61.98							Fee Schedule		5.67							Fee Schedule		71.28							Fee Schedule		57.64							Fee Schedule											71.28							Fee Schedule		57.64							Fee Schedule		
QUETIAPINE  50 MG (SEROQUEL) TABLET	250	RC	A9270	CPT				Both			21	9.45	0.01	71.28	0.01							Fee Schedule		15.54							Fee Schedule																				61.98							Fee Schedule		18.9							Fee Schedule		71.28							Fee Schedule		57.64							Fee Schedule											71.28							Fee Schedule		57.64							Fee Schedule		
QUETIAPINE 100MG (SEROQUEL) TABLET	250	RC	A9270	CPT				Both			10.5	4.73	0.01	9.45	0.01							Fee Schedule		7.77							Fee Schedule																													9.45							Fee Schedule																																															
QUETIAPINE 200MG (SEROQUEL) TABLET	250	RC	A9270	CPT				Both			40.95	18.43	0.01	36.86	0.01							Fee Schedule		30.3							Fee Schedule																													36.86							Fee Schedule																																															
"QUETIAPINE, SERUM (35299) (SEROQUEL)"	301	RC	80299	CPT				Both			219	98.55	13.42	197.1	13.42							Fee Schedule		18.64							Fee Schedule		19.2							Fee Schedule		18.64							Fee Schedule											197.1							Fee Schedule																				18.64							Fee Schedule																				
QUICK CLIP SINGLE #302321 (TRI-ANIM)	270	RC						Both			3.15	1.42	1.42	2.84	2.05							Fee Schedule		2.33							Fee Schedule																													2.84							Fee Schedule																																															
QUICK CORE NEEDLE 14G 11CM 20 G28107 IZI	272	RC	C1751	CPT				Both			113	50.85	50.85	101.7	69.11							Fee Schedule		83.62							Fee Schedule																													101.7							Fee Schedule																																															
QUICK CORE NEEDLE 14G 15CM 20 G07824 IZI	272	RC	C1751	CPT				Both			99.75	44.89	17.34	89.78	69.11							Fee Schedule		73.82							Fee Schedule																				18.64							Fee Schedule		89.78							Fee Schedule		21.44							Fee Schedule		17.34							Fee Schedule											21.44							Fee Schedule		17.34							Fee Schedule		
QUICK CORE NEEDLE 14G 6CM 20 G28100 IZI	272	RC	C1751	CPT				Both			113	50.85	50.85	101.7	69.11							Fee Schedule		83.62							Fee Schedule																													101.7							Fee Schedule																																															
QUICK CORE NEEDLE 14G 9CM 20 G27006 IZI	272	RC	C1751	CPT				Both			113	50.85	50.85	101.7	69.11							Fee Schedule		83.62							Fee Schedule																													101.7							Fee Schedule																																															
QUICK CORE NEEDLE 16G 11CM 10 G28129 IZI	272	RC	C1751	CPT				Both			113	50.85	50.85	101.7	69.11							Fee Schedule		83.62							Fee Schedule																													101.7							Fee Schedule																																															
QUICK CORE NEEDLE 16G 11CM 20 G28117 IZI	272	RC	C1751	CPT				Both			113	50.85	50.85	101.7	69.11							Fee Schedule		83.62							Fee Schedule																													101.7							Fee Schedule																																															
QUICK CORE NEEDLE 16G 15CM 10 G28110 IZI	272	RC	C1751	CPT				Both			113	50.85	50.85	101.7	69.11							Fee Schedule		83.62							Fee Schedule																													101.7							Fee Schedule																																															
QUICK CORE NEEDLE 16G 15CM 20 G07794 IZI	272	RC	C1751	CPT				Both			113	50.85	50.85	101.7	69.11							Fee Schedule		83.62							Fee Schedule																													101.7							Fee Schedule																																															
QUICK CORE NEEDLE 16G 9CM 20 G27007 IZI	272	RC	C1751	CPT				Both			113	50.85	50.85	101.7	69.11							Fee Schedule		83.62							Fee Schedule																													101.7							Fee Schedule																																															
QUICK CORE NEEDLE 18G 11CM 20 G28119 IZI	272	RC	C1751	CPT				Both			173	77.85	69.11	155.7	69.11							Fee Schedule		128.02							Fee Schedule																													155.7							Fee Schedule																																															
QUICK CORE NEEDLE 18G 15CM 10 G07819 IZI	272	RC	C1751	CPT				Both			113	50.85	50.85	101.7	69.11							Fee Schedule		83.62							Fee Schedule																													101.7							Fee Schedule																																															
QUICK CORE NEEDLE 18G 15CM 20 G07778 IZI	272	RC	C1751	CPT				Both			113	50.85	50.85	101.7	69.11							Fee Schedule		83.62							Fee Schedule																													101.7							Fee Schedule																																															
QUICK CORE NEEDLE 18GX9CM 20 G27010 IZI	272	RC	C1751	CPT				Both			117	52.65	52.65	105.3	69.11							Fee Schedule		86.58							Fee Schedule																													105.3							Fee Schedule																																															
QUICK CORE NEEDLE 20G 11CM 10 G28133 IZI	272	RC	C1751	CPT				Both			113	50.85	50.85	101.7	69.11							Fee Schedule		83.62							Fee Schedule																													101.7							Fee Schedule																																															
QUICK CORE NEEDLE 20G 9CM 10 G28126 IZI	272	RC	C1751	CPT				Both			113	50.85	50.85	101.7	69.11							Fee Schedule		83.62							Fee Schedule																													101.7							Fee Schedule																																															
QUICK CORE NEEDLE 20GX15CM 20 G07780 IZI	272	RC	C1751	CPT				Both			117	52.65	52.65	105.3	69.11							Fee Schedule		86.58							Fee Schedule																													105.3							Fee Schedule																																															
QUICK CORE NEEDLE 20GX9CM 20 G27015 IZI	272	RC	C1751	CPT				Both			117	52.65	52.65	105.3	69.11							Fee Schedule		86.58							Fee Schedule																													105.3							Fee Schedule																																															
QUICK CORE NEEDLE SET 20G 6.5CM G27018	272	RC	C1751	CPT				Both			151	67.95	67.95	135.9	69.11							Fee Schedule		111.74							Fee Schedule																													135.9							Fee Schedule																																															
QUINAGLUTE DURA TAB5	250	RC	A9270	CPT				Both			1.61	0.72	0.01	1.45	0.01							Fee Schedule		1.19							Fee Schedule																													1.45							Fee Schedule																																															
QUINAMM 260 MG TABLET	250	RC						Both			5.25	2.36	2.36	4.73	3.41							Fee Schedule		3.89							Fee Schedule																													4.73							Fee Schedule																																															
QUINAPRIL (ACCUPRIL) 20MG TABLET	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
QUINAPRIL 10 MG (ACCUPRIL) TABLET	250	RC						Both			4.2	1.89	1.89	3.78	2.73							Fee Schedule		3.11							Fee Schedule																													3.78							Fee Schedule																																															
QUINAPRIL 5MG (ACCUPRIL) TABLET	250	RC						Both			6.3	2.84	2.84	5.67	4.1							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
QUINIDINE 200 MG TABLET	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
QUINIDINE 766 SERUM	301	RC	80194	CPT				Both			87.15	39.22	12.98	78.44	12.98							Fee Schedule		16.22							Fee Schedule		15.04							Fee Schedule		14.6							Fee Schedule											78.44							Fee Schedule																				14.6							Fee Schedule																				
QUINIDINE GLUCONATE 324 MG TABLET UD	250	RC						Both			4.2	1.89	1.89	3.78	2.73							Fee Schedule		3.11							Fee Schedule																													3.78							Fee Schedule																																															
QUINIDINE SULFATE 300 MG TABLET UD	250	RC						Both			4.2	1.89	1.89	3.78	2.73							Fee Schedule		3.11							Fee Schedule																													3.78							Fee Schedule																																															
QUININE 325 MG CAPS	250	RC						Both			4.2	1.89	1.89	16.79	2.73							Fee Schedule		3.11							Fee Schedule																				14.6							Fee Schedule		3.78							Fee Schedule		16.79							Fee Schedule		13.58							Fee Schedule											16.79							Fee Schedule		13.58							Fee Schedule		
QVAR 40MCG HFA INHALER- 7.3GM	636	RC	J3535	CPT				Both			165.9	74.66	74.66	149.31		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	122.77							Fee Schedule																													149.31							Fee Schedule																																															
R F 15384 SYN FL REF LAB ONLY	302	RC	86430	CPT				Both			82.95	37.33	5.04	74.66	5.04							Fee Schedule		6.3							Fee Schedule		6.32							Fee Schedule		6.14							Fee Schedule											74.66							Fee Schedule																				6.14							Fee Schedule																				
RA TEST	302	RC	86431	CPT				Both			53.55	24.1	5.04	48.2	5.04							Fee Schedule		6.3							Fee Schedule		5.84							Fee Schedule		5.67							Fee Schedule											48.2							Fee Schedule																				5.67							Fee Schedule																				
RABIES IMMO GL ADMINISTRATION	260	RC	96372	CPT				Both			84	37.8	16.71	75.6	18.9							Fee Schedule		62.16							Fee Schedule											16.71							Fee Schedule											75.6							Fee Schedule																																															
RABIES VACCINE INJECTION	636	RC	90675	CPT				Both			500	225	5.71	454.77		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	454.77							Fee Schedule		341.94							Fee Schedule		204.82							Fee Schedule		6.14							Fee Schedule		450							Fee Schedule		7.06							Fee Schedule		5.71							Fee Schedule											7.06							Fee Schedule		5.71							Fee Schedule		
RACEPINEPHRINE INH SOL 2.25%	250	RC	J7699	CPT				Both			31.5	14.18	5.27	28.35	20.48							Fee Schedule		23.31							Fee Schedule																				5.67							Fee Schedule		28.35							Fee Schedule		6.52							Fee Schedule		5.27							Fee Schedule											6.52							Fee Schedule		5.27							Fee Schedule		
RAD TARGETING DEVICE	272	RC						Both			458.85	206.48	206.48	412.97	298.25							Fee Schedule		339.55							Fee Schedule																													412.97							Fee Schedule																																															
RADIAL ARTERIAL CATH.SET RA-04020	272	RC						Both			35	15.75	15.75	381.77	22.75							Fee Schedule		25.9							Fee Schedule																				331.98							Fee Schedule		31.5							Fee Schedule		381.77							Fee Schedule		308.74							Fee Schedule											381.77							Fee Schedule		308.74							Fee Schedule		
RADIAL JAW BIOPSY FORCEPS #M00513402	272	RC						Both			23	10.35	10.35	20.7	14.95							Fee Schedule		17.02							Fee Schedule																													20.7							Fee Schedule																																															
RADIAL JAW HOT BIOPSY FORCEPS #M00515033	272	RC						Both			55	24.75	24.75	49.5	35.75							Fee Schedule		40.7							Fee Schedule																													49.5							Fee Schedule																																															
RADIAL JAW JUMBO FORCEPS #M00513371	272	RC						Both			99	44.55	44.55	89.1	64.35							Fee Schedule		73.26							Fee Schedule																													89.1							Fee Schedule																																															
RAIN TRAP ADULT DISP. 5275P	271	RC						Both			4	1.8	1.8	3.6	2.6							Fee Schedule		2.96							Fee Schedule																													3.6							Fee Schedule																																															
RALOXIFENE HCL (EVISTA) 60MG TABLET UD	250	RC	A9270	CPT				Both			13.65	6.14	0.01	12.29	0.01							Fee Schedule		10.1							Fee Schedule																													12.29							Fee Schedule																																															
RAMIPRIL  1.25MG (ALTACE) CAPSULE	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
RAMIPRIL  2.5MG (ALTACE) CAPSULE	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
RAMIPRIL  5MG (ALTACE) CAPSULE	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
RAMIPRIL 1.25 MG CAPSULE UD	250	RC						Both			4.2	1.89	1.89	3.78	2.73							Fee Schedule		3.11							Fee Schedule																													3.78							Fee Schedule																																															
RAMIPRIL 10MG (ALTACE) CAPSULE	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
RANITIDINE 15 MG/ML UD SYRUP	250	RC						Both			25.61	11.52	11.52	23.05	16.65							Fee Schedule		18.95							Fee Schedule																													23.05							Fee Schedule																																															
RANITIDINE 150MG TABLET	250	RC						Both			5.66	2.55	2.55	5.09	3.68							Fee Schedule		4.19							Fee Schedule																													5.09							Fee Schedule																																															
RANITIDINE 300MG TABLET	250	RC						Both			10.5	4.73	4.73	9.45	6.83							Fee Schedule		7.77							Fee Schedule																													9.45							Fee Schedule																																															
RANOLAZINE ER (RANEXA) 500MG TABLET	250	RC	A9270	CPT				Both			21	9.45	0.01	18.9	0.01							Fee Schedule		15.54							Fee Schedule																													18.9							Fee Schedule																																															
RAPAMYCIN 36712 LAV TOP TUBE	301	RC	80195	CPT				Both			113.4	51.03	12.21	102.06	12.21							Fee Schedule		15.26							Fee Schedule		14.14							Fee Schedule		13.73							Fee Schedule											102.06							Fee Schedule																				13.73							Fee Schedule																				
RAPE KIT	271	RC						Both			6.3	2.84	2.84	5.67	4.1							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
RAPE KIT	271	RC						Both			6.3	2.84	2.84	5.67	4.1							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
RAPID FETAL SCREEN	300	RC	85461	CPT				Both			158.55	71.35	6.74	142.7	6.74							Fee Schedule		9.36							Fee Schedule		9.64							Fee Schedule		9.36							Fee Schedule		13.73							Fee Schedule		142.7							Fee Schedule		15.79							Fee Schedule		12.77							Fee Schedule		9.36							Fee Schedule		15.79							Fee Schedule		12.77							Fee Schedule		
RAPID FIRE SUPERVIEW MULTIPLE BAND LIGAT	272	RC						Both			987	444.15	444.15	888.3	641.55							Fee Schedule		730.38							Fee Schedule																													888.3							Fee Schedule																																															
RAPLON 20MG/ML 5ML VIAL (RAPACURONIUM)	250	RC						Both			10.14	4.56	4.56	9.13	6.59							Fee Schedule		7.5							Fee Schedule																													9.13							Fee Schedule																																															
RASP LARGE TEAR 116	272	RC						Both			371.7	167.27	8.7	334.53	241.61							Fee Schedule		275.06							Fee Schedule																				9.36							Fee Schedule		334.53							Fee Schedule		10.76							Fee Schedule		8.7							Fee Schedule											10.76							Fee Schedule		8.7							Fee Schedule		
RASP LARGE TEAR CROSS CUT 114	272	RC						Both			371.7	167.27	167.27	334.53	241.61							Fee Schedule		275.06							Fee Schedule																													334.53							Fee Schedule																																															
RASP RIORDAN SM 126-1	272	RC						Both			371.7	167.27	167.27	334.53	241.61							Fee Schedule		275.06							Fee Schedule																													334.53							Fee Schedule																																															
RAZADYNE 4 MG TABLET(GALANTAMINE)	250	RC						Both			8.4	3.78	3.78	7.56	5.46							Fee Schedule		6.22							Fee Schedule																													7.56							Fee Schedule																																															
RAZOR CUT 3.5	272	RC						Both			202.65	91.19	91.19	182.39	131.72							Fee Schedule		149.96							Fee Schedule																													182.39							Fee Schedule																																															
RAZOR CUT 4.5 BLADE	272	RC						Both			202.65	91.19	91.19	182.39	131.72							Fee Schedule		149.96							Fee Schedule																													182.39							Fee Schedule																																															
RAZOR CUT 5.5 BLADE	272	RC						Both			269.85	121.43	121.43	242.87	175.4							Fee Schedule		199.69							Fee Schedule																													242.87							Fee Schedule																																															
RAZOR CUT BLADE 3.5MM   4422 SMITHNEPHEW	272	RC						Both			202.65	91.19	91.19	182.39	131.72							Fee Schedule		149.96							Fee Schedule																													182.39							Fee Schedule																																															
RAZOR CUT BLADE 4.5MM   4280 SMITHNEPHEW	272	RC						Both			202.65	91.19	91.19	182.39	131.72							Fee Schedule		149.96							Fee Schedule																													182.39							Fee Schedule																																															
RAZOR CUT BLADE 4.5MM 7205318 SMITHNEPHE	272	RC						Both			202.65	91.19	91.19	182.39	131.72							Fee Schedule		149.96							Fee Schedule																													182.39							Fee Schedule																																															
RBC	305	RC	85041	CPT				Both			23.1	10.4	2.69	20.79	2.69							Fee Schedule		3.35							Fee Schedule		3.11							Fee Schedule		3.02							Fee Schedule											20.79							Fee Schedule																				3.02							Fee Schedule																				
REBETRON 1000/PEN COMBO	636	RC	J9213	CPT				Both			2310	1039.5	1039.5	2079		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1709.4							Fee Schedule																													2079							Fee Schedule																																															
RECOMBIVAX HB 10MCG/ML VACCINE(ADULT)	636	RC	90746	CPT				Both			42	18.9	18.9	87.95		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	31.08							Fee Schedule		77.4							Fee Schedule		87.95							Fee Schedule											37.8							Fee Schedule																																															
RECOTHROM THRMB TOPICAL 5000IU	636	RC	A9270	CPT				Both			309.6	139.32	2.81	278.64		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	229.1							Fee Schedule																				3.02							Fee Schedule		278.64							Fee Schedule		3.47							Fee Schedule		2.81							Fee Schedule											3.47							Fee Schedule		2.81							Fee Schedule		
RECTAL TUBE 30 FR #8006410	271	RC						Both			48.3	21.74	21.74	43.47	31.4							Fee Schedule		35.74							Fee Schedule																													43.47							Fee Schedule																																															
CESAREAN SECTION WITHOUT STERILIZATION WITH CC					787	DRG		Inpatient			20386.71	9174.02	9174.02	9174.02							0		No services performed during 15 month lookback period. 				6739.83	6739.83	6739.83	1 through 10									0		No services performed during 15 month lookback period				4194.84	4194.84	4194.84	1 through 10									0		No services provided during 15 month lookback period				20738.46	20738.46	20738.46	1 through 10									0	Fee Schedule	No services provided during 15 month lookback period				5199.46	5199.46	5199.46	1 through 10	Fee Schedule								0		No services provided during 15 month lookback							0		No services provided during 15 month lookback period							0	Fee Schedule	No services provided during 15 month lookback period	
CESAREAN SECTION WITHOUT STERILIZATION WITHOUT CC/MCC					788	DRG		Inpatient			20785.37	9353.42	9353.42	9353.42				3423.88	3205.58	3642.18	1 through 10						4011.72	2027.48	10052.97	14									0		No services performed during 15 month lookback period				3576.79	3576.79	3576.79	17									0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period				4226.45	4226.45	4226.45	1 through 10									0		No services provided during 15 month lookback							0		No services provided during 15 month lookback period				4750.11	4750.11	4750.11	1 through 10			
RED ROBBINS 10FR #277710	272	RC						Both			2.1	0.95	0.95	1.89	1.37							Fee Schedule		1.55							Fee Schedule																													1.89							Fee Schedule																																															
RED ROBBINS 12FR #277712	272	RC						Both			3	1.35	1.35	2.7	1.95							Fee Schedule		2.22							Fee Schedule																													2.7							Fee Schedule																																															
RED ROBBINS 14FR #277714	272	RC						Both			2	0.9	0.9	1.8	1.3							Fee Schedule		1.48							Fee Schedule																													1.8							Fee Schedule																																															
RED ROBBINS 16FR #277716	272	RC						Both			3	1.35	1.35	2.7	1.95							Fee Schedule		2.22							Fee Schedule																													2.7							Fee Schedule																																															
RED ROBBINS 18FR #277718	272	RC						Both			2	0.9	0.9	1.8	1.3							Fee Schedule		1.48							Fee Schedule																													1.8							Fee Schedule																																															
RED ROBBINS 24FR	272	RC						Both			9.45	4.25	4.25	8.51	6.14							Fee Schedule		6.99							Fee Schedule																													8.51							Fee Schedule																																															
REDUCERS (FOR 18MM)	272	RC						Both			27.3	12.29	12.29	24.57	17.75							Fee Schedule		20.2							Fee Schedule																													24.57							Fee Schedule																																															
REGIONAL BLOCK NERVE			64415	CPT				Both			868.45	390.8	85.53	781.61	85.53							Fee Schedule		642.65							Fee Schedule																													781.61							Fee Schedule																																															
REGIONAL BLOCK NERVE			64420	CPT				Both			265	119.25	35.18	238.5	86.88							Fee Schedule		196.1							Fee Schedule											35.18							Fee Schedule											238.5							Fee Schedule																																															
REGIONAL BLOCK NERVE			64421	CPT				Both			288.75	129.94	48.71	259.88	119.34							Fee Schedule		213.68							Fee Schedule											48.71							Fee Schedule											259.88							Fee Schedule																																															
REGRANEX GEL.0.01%	636	RC	S0157	CPT				Both			908.25	408.71	408.71	817.43		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	672.11							Fee Schedule																													817.43							Fee Schedule																																															
RELEFACT TRH	636	RC	J2725	CPT				Both			74.93	33.72	33.72	67.44		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	55.45							Fee Schedule																													67.44							Fee Schedule																																															
RELIANT BALLOON CATHETER #REL46	272	RC	C1725	CPT				Both			1470	661.5	93.3	1323	93.3							Fee Schedule		1087.8							Fee Schedule																													1323							Fee Schedule																																															
RELISTOR 12 MG/0.6 ML VIAL	636	RC	J2212	CPT				Both			672.3	302.54	302.54	605.07		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	497.5							Fee Schedule																													605.07							Fee Schedule																																															
REMDESIVIR 100MG VIAL	636	RC	J0248	CPT				Both			2057.34	925.8	6.9	1851.61		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	6.9							Fee Schedule		7.1							Fee Schedule																				1851.61							Fee Schedule																																															
REMDESIVIR 100MG/NS 100ML  IVPB	636	RC	J0248	CPT				Both			1890	850.5	6.9	1701		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	6.9							Fee Schedule		7.1							Fee Schedule																				1701							Fee Schedule																																															
REMDESIVIR 200MG/250ML NS IVPB	636	RC	J0248	CPT				Both			3756	1690.2	6.9	3380.4		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	6.9							Fee Schedule		7.1							Fee Schedule																				3380.4							Fee Schedule																																															
REMOVER WIPES 7760	270	RC	A4456	CPT				Both			1	0.45	0.22	7.93	0.22							Fee Schedule		0.74							Fee Schedule		0.36							Fee Schedule											6.9							Fee Schedule		0.9							Fee Schedule		7.93							Fee Schedule		6.42							Fee Schedule											7.93							Fee Schedule		6.42							Fee Schedule		
"NEONATES, DIED OR TRANSFERRED TO ANOTHER ACUTE CARE FACILITY"					789	DRG		Inpatient			3109.02	1399.06	1399.06	1399.06							0		No services performed during 15 month lookback period. 				1596.23	1596.23	1596.23	1 through 10									0		No services performed during 15 month lookback period				827.26	827.26	827.26	1 through 10									0		No services provided during 15 month lookback period				662.7	662.7	662.7	1 through 10									0	Fee Schedule	No services provided during 15 month lookback period				2136.39	2136.39	2136.39	1 through 10	Fee Schedule								0		No services provided during 15 month lookback							0		No services provided during 15 month lookback period				283.5	283.5	283.5	1 through 10	Fee Schedule		
PREMATURITY WITHOUT MAJOR PROBLEMS					792	DRG		Inpatient			3591.86	1616.34	1616.34	1616.34							0		No services performed during 15 month lookback period. 				995.04	995.04	995.04	1 through 10									0		No services performed during 15 month lookback period				1338.37	1338.37	1338.37	15									0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0	Fee Schedule	No services provided during 15 month lookback period				4342.3	4342.3	4342.3	1 through 10	Fee Schedule								0		No services provided during 15 month lookback							0		No services provided during 15 month lookback period							0	Fee Schedule	No services provided during 15 month lookback period	
FULL TERM NEONATE WITH MAJOR PROBLEMS					793	DRG		Inpatient			3256.5	1465.42	1465.42	1465.42							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0	Fee Schedule	No services provided during 15 month lookback period				1160.27	1160.27	1160.27	1 through 10	Fee Schedule								0		No services provided during 15 month lookback							0		No services provided during 15 month lookback period				949.98	949.98	949.98	1 through 10	Fee Schedule		
RENAL PANEL	301	RC	80069	CPT				Both			149.1	67.1	7.72	134.19	7.72							Fee Schedule		9.65							Fee Schedule		8.94							Fee Schedule		8.68							Fee Schedule											134.19							Fee Schedule																				8.68							Fee Schedule																				
RENAL SOFTGEL CAPS	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
RENA-VITE RX TABLETS UD	250	RC						Both			6.3	2.84	2.84	5.67	4.1							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
RENIN LEV PLAS LAV TU 16846 FZ	301	RC	84244	CPT				Both			138.6	62.37	8.07	124.74	19.55							Fee Schedule		24.44							Fee Schedule		22.65							Fee Schedule		21.99							Fee Schedule		8.68							Fee Schedule		124.74							Fee Schedule		9.98							Fee Schedule		8.07							Fee Schedule		21.99							Fee Schedule		9.98							Fee Schedule		8.07							Fee Schedule		
RENVELA 800 MG TABS	250	RC						Both			18.9	8.51	8.51	17.01	12.29							Fee Schedule		13.99							Fee Schedule																													17.01							Fee Schedule																																															
REPLETE READY TO HANG 1000 ML	250	RC						Both			22.22	10	10	20	14.44							Fee Schedule		16.44							Fee Schedule																													20							Fee Schedule																																															
RESCUE RAT TOOTH  FORCEPS M00527651	272	RC						Both			234	105.3	20.45	210.6	152.1							Fee Schedule		173.16							Fee Schedule																				21.99							Fee Schedule		210.6							Fee Schedule		25.29							Fee Schedule		20.45							Fee Schedule											25.29							Fee Schedule		20.45							Fee Schedule		
RESECTION ELECTRODE A22251C	272	RC						Both			383.25	172.46	172.46	344.93	249.11							Fee Schedule		283.61							Fee Schedule																													344.93							Fee Schedule																																															
RESECTOR 4.0  275-542-000(STRYKER ENDOSC	272	RC						Both			197.4	88.83	88.83	177.66	128.31							Fee Schedule		146.08							Fee Schedule																													177.66							Fee Schedule																																															
RESECTOR 5.0  275-552-000(STRYKER ENDOSC	272	RC						Both			197.4	88.83	88.83	177.66	128.31							Fee Schedule		146.08							Fee Schedule																													177.66							Fee Schedule																																															
RESOLUTION CLIP #M00522611	278	RC	C1769	CPT				Both			499	224.55	224.55	449.1		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	369.26							Fee Schedule																													449.1							Fee Schedule																																															
RESOLUTION CLIP #M00522612	278	RC	C1877	CPT				Both			483	217.35	217.35	434.7		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	357.42							Fee Schedule																													434.7							Fee Schedule																																															
RESOLUTION ULTRA CLIP #M00521400	278	RC						Both			808	363.6	363.6	727.2		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	597.92							Fee Schedule																													727.2							Fee Schedule																																															
NEONATE WITH OTHER SIGNIFICANT PROBLEMS					794	DRG		Inpatient			3514.77	1581.65	1581.65	1581.65							0		No services performed during 15 month lookback period. 				2230.34	2230.34	2230.34	1 through 10									0		No services performed during 15 month lookback period				732.93	732.93	732.93	67									0		No services provided during 15 month lookback period				2896.56	2896.56	2896.56	1 through 10									0		No services provided during 15 month lookback period				1109.95	1109.95	1109.95	17									0		No services provided during 15 month lookback							0		No services provided during 15 month lookback period				1113.99	1113.99	1113.99	1 through 10			
NORMAL NEWBORN					795	DRG		Inpatient			2775.66	1249.05	1249.05	1249.05				870.48	870.48	870.48	1 through 10						974.17	867.82	2942.53	26									0		No services performed during 15 month lookback period				634.74	634.74	634.74	1 through 10									0		No services provided during 15 month lookback period				2110.92	2110.92	2110.92	1 through 10									0		No services provided during 15 month lookback period				681.96	681.96	681.96	29									0		No services provided during 15 month lookback							0		No services provided during 15 month lookback period				734.9	734.9	734.9	25			
VAGINAL DELIVERY WITH STERILIZATION AND/OR D&C WITH CC					797	DRG		Inpatient			29811.9	13415.35	13415.35	13415.35							0		No services performed during 15 month lookback period. 				9573.38	9573.38	9573.38	1 through 10									0		No services performed during 15 month lookback period				4226.48	4226.48	4226.48	1 through 10									0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period	
VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITH MCC					805	DRG		Inpatient			11660.81	5247.37	5247.37	5247.37							0		No services performed during 15 month lookback period. 				13754.5	13754.5	13754.5	1 through 10									0		No services performed during 15 month lookback period				3737.9	3737.9	3737.9	1 through 10									0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period	
VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITH CC					806	DRG		Inpatient			10118.86	4553.49	4553.49	4553.49				5611.23	5611.23	5611.23	1 through 10						4147.81	4147.81	4147.81	1 through 10									0		No services performed during 15 month lookback period				4315.87	4315.87	4315.87	40									0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period				3062.8	3062.8	3062.8	1 through 10									0		No services provided during 15 month lookback							0		No services provided during 15 month lookback period				1889.88	1889.88	1889.88	1 through 10			
VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITHOUT CC/MCC					807	DRG		Inpatient			10300	4635	4635	4635				4992.81	4992.81	4992.81	1 through 10						3519.46	2583.37	8072.36	21									0		No services performed during 15 month lookback period				3443.4	3443.4	3443.4	1 through 10									0		No services provided during 15 month lookback period				6071.16	6071.16	6071.16	1 through 10									0		No services provided during 15 month lookback period				3146.82	3146.82	3146.82	25									0		No services provided during 15 month lookback							0		No services provided during 15 month lookback period				3357.4	3357.4	3357.4	26			
RED BLOOD CELL DISORDERS WITH MCC					811	DRG		Inpatient			21412.49	9635.62	9635.62	9635.62							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period	
RED BLOOD CELL DISORDERS WITHOUT MCC					812	DRG		Inpatient			24682.97	11107.34	11107.34	11107.34							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period				2553.52	2553.52	2553.52	1 through 10									0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback				7841.09	7841.09	7841.09	1 through 10									0		No services provided during 15 month lookback period	
COAGULATION DISORDERS					813	DRG		Inpatient			28186.41	12683.88	12683.88	12683.88							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period	
"RESPIRATORY VIRAL PANEL, PCR 95512"	301	RC	87633	CPT				Both			884	397.8	370.48	795.6	370.48							Fee Schedule		463.09							Fee Schedule		429.28							Fee Schedule		416.78							Fee Schedule											795.6							Fee Schedule																				416.78							Fee Schedule																				
RESPIRATORY VIRUS SCREEN 14860 SWAB	302	RC	87300	CPT				Both			101.85	45.83	10.66	91.67	10.66							Fee Schedule		13.32							Fee Schedule		12.34							Fee Schedule		11.98							Fee Schedule											91.67							Fee Schedule																				11.98							Fee Schedule																				
RESTORE CALCICARE 4X4 529937	270	RC	A6196	CPT				Both			6	2.7	2.7	10.8	6.62							Fee Schedule		4.44							Fee Schedule		10.8							Fee Schedule		8.28							Fee Schedule											5.4							Fee Schedule																																															
RESTORE CALCICARE 4X8 529939	272	RC	A6197	CPT				Both			14	6.3	6.3	479.3	14.8							Fee Schedule		10.36							Fee Schedule		24.14							Fee Schedule		18.5							Fee Schedule		416.78							Fee Schedule		12.6							Fee Schedule		479.3							Fee Schedule		387.61							Fee Schedule											479.3							Fee Schedule		387.61							Fee Schedule		
RESTORE CALCICARE ROPE 12  #529940	272	RC	A6196	CPT				Both			7	3.15	3.15	13.78	6.62							Fee Schedule		5.18							Fee Schedule		10.8							Fee Schedule		8.28							Fee Schedule		11.98							Fee Schedule		6.3							Fee Schedule		13.78							Fee Schedule		11.14							Fee Schedule											13.78							Fee Schedule		11.14							Fee Schedule		
RESTORE CONTACT LAYER # 509338	272	RC						Both			27.3	12.29	9.76	24.57	17.75							Fee Schedule		20.2							Fee Schedule																				10.49							Fee Schedule		24.57							Fee Schedule		12.06							Fee Schedule		9.76							Fee Schedule											12.06							Fee Schedule		9.76							Fee Schedule		
RESTORE CONTACT LAYER 2X2 506487	272	RC						Both			6.3	2.84	2.84	26.96	4.1							Fee Schedule		4.66							Fee Schedule																				23.44							Fee Schedule		5.67							Fee Schedule		26.96							Fee Schedule		21.8							Fee Schedule											26.96							Fee Schedule		21.8							Fee Schedule		
RESTORE CONTACT LAYER 4X5 506488	272	RC	A6207	CPT				Both			13.65	6.14	6.14	12.29	6.61							Fee Schedule		10.1							Fee Schedule		10.78							Fee Schedule		8.26							Fee Schedule		10.49							Fee Schedule		12.29							Fee Schedule		12.06							Fee Schedule		9.76							Fee Schedule											12.06							Fee Schedule		9.76							Fee Schedule		
RESTORE CONTACT LAYER 6X8 506489	272	RC						Both			27.3	12.29	12.29	24.57	17.75							Fee Schedule		20.2							Fee Schedule																													24.57							Fee Schedule																																															
RESTORE CONTACT SILVER 509341	272	RC						Both			26.25	11.81	11.81	23.63	17.06							Fee Schedule		19.43							Fee Schedule																													23.63							Fee Schedule																																															
RESTORE CONTACT SILVER 509342	272	RC						Both			52.5	23.63	9.74	47.25	34.13							Fee Schedule		38.85							Fee Schedule																				10.47							Fee Schedule		47.25							Fee Schedule		12.04							Fee Schedule		9.74							Fee Schedule											12.04							Fee Schedule		9.74							Fee Schedule		
RESTORE FOAM DRESSING 2X2 509380	272	RC						Both			7.35	3.31	3.31	6.62	4.78							Fee Schedule		5.44							Fee Schedule																													6.62							Fee Schedule																																															
RESTORE FOAM DRESSING 4X4  #509381	272	RC						Both			7.35	3.31	3.31	6.62	4.78							Fee Schedule		5.44							Fee Schedule																													6.62							Fee Schedule																																															
RESTORE FOAM DRESSING 6X6 509382	272	RC						Both			18.9	8.51	8.51	17.01	12.29							Fee Schedule		13.99							Fee Schedule																													17.01							Fee Schedule																																															
RESTORE FOAM SILVER 509345	272	RC						Both			23.1	10.4	10.4	20.79	15.02							Fee Schedule		17.09							Fee Schedule																													20.79							Fee Schedule																																															
RESTORE FOAM SILVER 509346	272	RC						Both			51.45	23.15	23.15	46.31	33.44							Fee Schedule		38.07							Fee Schedule																													46.31							Fee Schedule																																															
RESTORE HYDROGEL 3 INCH #17264	272	RC	A6260	CPT				Both			26	11.7	0.52	23.4	0.52							Fee Schedule		19.24							Fee Schedule																													23.4							Fee Schedule																																															
RESTORE HYDROGEL 4X4 529972	272	RC	A6248	CPT				Both			9.45	4.25	4.25	23.84	14.63							Fee Schedule		6.99							Fee Schedule		23.84							Fee Schedule		18.29							Fee Schedule											8.51							Fee Schedule																																															
RESTORE HYDROGEL STRIP	272	RC	A6248	CPT				Both			40.95	18.43	14.63	36.86	14.63							Fee Schedule		30.3							Fee Schedule		23.84							Fee Schedule		18.29							Fee Schedule											36.86							Fee Schedule																																															
RESTORE PLUS 4X4 HYDROCOLLOID 519956	272	RC	A6237	CPT				Both			5	2.25	2.25	11.61	7.13							Fee Schedule		3.7							Fee Schedule		11.61							Fee Schedule		8.91							Fee Schedule											4.5							Fee Schedule																																															
RESTORE PLUS 8X8 HYDROCOLLOID DSG.	272	RC	A6233	CPT				Both			75.6	34.02	17.26	68.04	17.26							Fee Schedule		55.94							Fee Schedule		28.15							Fee Schedule											23.15							Fee Schedule		68.04							Fee Schedule		26.62							Fee Schedule		21.53							Fee Schedule											26.62							Fee Schedule		21.53							Fee Schedule		
RESTORE PLUS CONFORMABLE EDGE 519959	272	RC	A6237	CPT				Both			8.4	3.78	3.78	26.62	7.13							Fee Schedule		6.22							Fee Schedule		11.61							Fee Schedule		8.91							Fee Schedule		23.15							Fee Schedule		7.56							Fee Schedule		26.62							Fee Schedule		21.53							Fee Schedule											26.62							Fee Schedule		21.53							Fee Schedule		
RESTORELLE Y-CONTOUR MESH COI501520	272	RC	C1781	CPT				Both			63	28.35	10.48	478.48	478.48							Fee Schedule		46.62							Fee Schedule																				11.27							Fee Schedule		56.7							Fee Schedule		12.96							Fee Schedule		10.48							Fee Schedule											12.96							Fee Schedule		10.48							Fee Schedule		
RESTRAINT LIMB	270	RC						Both			43.05	19.37	19.37	38.75	27.98							Fee Schedule		31.86							Fee Schedule																				27.33							Fee Schedule		38.75							Fee Schedule		31.43							Fee Schedule		25.42							Fee Schedule											31.43							Fee Schedule		25.42							Fee Schedule		
RESTRAINTS WRIST/ANKLE #M9401	270	RC	E0710	CPT				Both			7	3.15	3.15	16.8	16.8							Fee Schedule		5.18							Fee Schedule																				11.27							Fee Schedule		6.3							Fee Schedule		12.96							Fee Schedule		10.48							Fee Schedule											12.96							Fee Schedule		10.48							Fee Schedule		
RESUSCITATION	480	RC	92950	CPT				Both			1123.5	505.58	200.05	1035	600							Per Diem		831.39							Fee Schedule											200.05							Fee Schedule											1011.15							Fee Schedule																				1035							Per Diem																				
RETENTION BOLSTER 450G	272	RC						Both			6.3	2.84	2.84	5.67	4.1							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
RETENTION BRIDGE RSB5	272	RC						Both			21	9.45	9.45	18.9	13.65							Fee Schedule		15.54							Fee Schedule																													18.9							Fee Schedule																																															
RETEVASE (2) 18.1MG (10UNITS) VIALS	636	RC	J2993	CPT				Both			10356.15	4660.27	2991.71	9320.54		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	3021.04							Fee Schedule		2991.71							Fee Schedule																				9320.54							Fee Schedule																																															
RETIC COUNT AUTOMATED	305	RC	85045	CPT				Both			52.5	23.63	3.55	47.25	3.55							Fee Schedule		4.44							Fee Schedule		4.11							Fee Schedule		3.99							Fee Schedule											47.25							Fee Schedule																				3.99							Fee Schedule																				
RETICULIN ANTIBODIES 37520  SERUM 2ML	302	RC	86255	CPT				Both			187.95	84.58	10.71	169.16	10.71							Fee Schedule		13.39							Fee Schedule		12.41							Fee Schedule		12.05							Fee Schedule											169.16							Fee Schedule																				12.05							Fee Schedule																				
RETINOL BINDING PROTEIN	300	RC	83883	CPT				Both			210	94.5	12.09	3340.26	12.09							Fee Schedule		15.11							Fee Schedule		14.01							Fee Schedule		13.6							Fee Schedule		2904.58							Fee Schedule		189							Fee Schedule		3340.26							Fee Schedule		2701.25							Fee Schedule		13.6							Fee Schedule		3340.26							Fee Schedule		2701.25							Fee Schedule		
RETRIEVAL BASKET FG-V431P	272	RC						Both			663.6	298.62	3.71	597.24	431.34							Fee Schedule		491.06							Fee Schedule																				3.99							Fee Schedule		597.24							Fee Schedule		4.59							Fee Schedule		3.71							Fee Schedule											4.59							Fee Schedule		3.71							Fee Schedule		
RETRIEVAL NET ROTH 00711052	270	RC						Both			286.65	128.99	11.21	257.99	186.32							Fee Schedule		212.12							Fee Schedule																				12.05							Fee Schedule		257.99							Fee Schedule		13.86							Fee Schedule		11.21							Fee Schedule											13.86							Fee Schedule		11.21							Fee Schedule		
RETRIVAL BASKET MICROVASIVE	272	RC						Both			1197	538.65	12.65	1077.3	778.05							Fee Schedule		885.78							Fee Schedule																				13.6							Fee Schedule		1077.3							Fee Schedule		15.64							Fee Schedule		12.65							Fee Schedule											15.64							Fee Schedule		12.65							Fee Schedule		
RETRO PYELOGRAM	329	RC	74420	CPT				Both			378	170.1	41.75	369.01	369.01							Fee Schedule		41.75							Fee Schedule											74.39							Fee Schedule											340.2							Fee Schedule																				318							Per Diem																				
RETROVIR 100 MG CAPS	250	RC						Both			6.3	2.84	2.84	5.67	4.1							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
REVATIO 20MG TABLET(SILDENAFIL)	250	RC	A9270	CPT				Both			33.6	15.12	0.01	30.24	0.01							Fee Schedule		24.86							Fee Schedule																													30.24							Fee Schedule																																															
REZULIN:200 MG (TROGLITAZONE)	250	RC						Both			9.36	4.21	4.21	8.42	6.08							Fee Schedule		6.93							Fee Schedule																													8.42							Fee Schedule																																															
RH PHENOTYPE 794  WHOLD BLOOD 5.0 ML	301	RC	84402	CPT				Both			145.95	65.68	22.64	131.36	22.64							Fee Schedule		28.3							Fee Schedule		26.23							Fee Schedule		25.47							Fee Schedule											131.36							Fee Schedule																				25.47							Fee Schedule																				
RH TYPE	300	RC	86901	CPT				Both			48.3	21.74	2.66	43.47	2.66							Fee Schedule		3.32							Fee Schedule		3.08							Fee Schedule		2.99							Fee Schedule											43.47							Fee Schedule																				2.99							Fee Schedule																				
RHINOCORT AQ INHALER	636	RC	J3535	CPT				Both			181.44	81.65	81.65	163.3		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	134.27							Fee Schedule																													163.3							Fee Schedule																																															
RHINOCORT INHALER	636	RC	J3535	CPT				Both			89.27	40.17	23.69	80.34		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	66.06							Fee Schedule																				25.47							Fee Schedule		80.34							Fee Schedule		29.29							Fee Schedule		23.69							Fee Schedule											29.29							Fee Schedule		23.69							Fee Schedule		
RHOGAM (LAB)	300	RC	86901	CPT				Both			10	4.5	2.66	9	2.66							Fee Schedule		3.32							Fee Schedule		3.08							Fee Schedule		2.99							Fee Schedule		2.99							Fee Schedule		9							Fee Schedule		3.44							Fee Schedule		2.78							Fee Schedule		2.99							Fee Schedule		3.44							Fee Schedule		2.78							Fee Schedule		
RHOGAM 300 MCG INJECTION	636	RC	J2790	CPT				Both			132.3	59.54	59.54	119.07		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	97.9							Fee Schedule		87.68							Fee Schedule		110.54							Fee Schedule											119.07							Fee Schedule																																															
RI ANTIBODY SCREEN 10140 SERUM 0.5 ML	302	RC	86255	CPT				Both			178.5	80.33	10.71	160.65	10.71							Fee Schedule		13.39							Fee Schedule		12.41							Fee Schedule		12.05							Fee Schedule											160.65							Fee Schedule																				12.05							Fee Schedule																				
RIB BELT 6  FEMALE UNIVERSAL #79-89060	274	RC	A4467	CPT				Both			10	4.5	2.78	9		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	7.4							Fee Schedule																				2.99							Fee Schedule		9							Fee Schedule		3.44							Fee Schedule		2.78							Fee Schedule											3.44							Fee Schedule		2.78							Fee Schedule		
RIB BELT 8  MALE UNIVERSAL 79-89150	274	RC	A4467	CPT				Both			12	5.4	5.4	97.89		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	8.88							Fee Schedule																				85.13							Fee Schedule		10.8							Fee Schedule		97.89							Fee Schedule		79.17							Fee Schedule											97.89							Fee Schedule		79.17							Fee Schedule		
RIB BELT MALE UNI	274	RC	A4467	CPT				Both			40.95	18.43	11.21	36.86		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	30.3							Fee Schedule																				12.05							Fee Schedule		36.86							Fee Schedule		13.86							Fee Schedule		11.21							Fee Schedule											13.86							Fee Schedule		11.21							Fee Schedule		
RIBAVIRIN 200 MG TABLET	250	RC						Both			28.35	12.76	12.76	25.52	18.43							Fee Schedule		20.98							Fee Schedule																													25.52							Fee Schedule																																															
RIBS BILATERAL	320	RC	71110	CPT				Both			315	141.75	20.55	318	20.55							Fee Schedule		23.89							Fee Schedule											22.35							Fee Schedule											283.5							Fee Schedule																				318							Per Diem																				
RIBS LT 2V	320	RC	71100	CPT				Both			315	141.75	16.3	318	17.93							Fee Schedule		20.97							Fee Schedule											16.3							Fee Schedule											283.5							Fee Schedule																				318							Per Diem																				
RIBS RT 2V	320	RC	71100	CPT				Both			315	141.75	16.3	318	17.93							Fee Schedule		20.97							Fee Schedule											16.3							Fee Schedule											283.5							Fee Schedule																				318							Per Diem																				
RIBS UNILAT INCLUDING POSTEROANTEIOR 3 V	320	RC	71101	CPT				Both			320	144	19.13	318	19.97							Fee Schedule		23.24							Fee Schedule											19.13							Fee Schedule											288							Fee Schedule																				318							Per Diem																				
RIFADIN 600MG (RIFAMPIN) VIAL	636	RC	J3490	CPT				Both			675.15	303.82	303.82	607.64		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	499.61							Fee Schedule																													607.64							Fee Schedule																																															
RIFAMPIN 300 MG CAPSULE	250	RC	A9270	CPT				Both			7.35	3.31	0.01	6.62	0.01							Fee Schedule		5.44							Fee Schedule																													6.62							Fee Schedule																																															
RING 3/4 165MM ID	278	RC	C1713	CPT				Both			1981.35	891.61	891.61	1783.22		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1466.2							Fee Schedule																													1783.22							Fee Schedule																																															
RISEDRONATE 35 MG WEEKLY TABLET UD	250	RC						Both			58.8	26.46	26.46	52.92	38.22							Fee Schedule		43.51							Fee Schedule																													52.92							Fee Schedule																																															
RISPERDAL CONSTA 25MG IM INJECTION	636	RC	J2794	CPT				Both			945	425.25	10.79	850.5		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	10.79							Fee Schedule		11.52							Fee Schedule																				850.5							Fee Schedule																																															
RISPERIDONE & METABOLITE  2339	301	RC	80299	CPT				Both			303	136.35	13.42	272.7	13.42							Fee Schedule		18.64							Fee Schedule		19.2							Fee Schedule		18.64							Fee Schedule											272.7							Fee Schedule																				18.64							Fee Schedule																				
risperiDONE 0.25MG (RISPERDAL) TABLET	250	RC	A9270	CPT				Both			11.55	5.2	0.01	10.4	0.01							Fee Schedule		8.55							Fee Schedule																													10.4							Fee Schedule																																															
risperiDONE 1MG (RISPERDAL) TABLET	250	RC	A9270	CPT				Both			7.35	3.31	0.01	12.86	0.01							Fee Schedule		5.44							Fee Schedule																				11.18							Fee Schedule		6.62							Fee Schedule		12.86							Fee Schedule		10.4							Fee Schedule											12.86							Fee Schedule		10.4							Fee Schedule		
RISTOCETION COFACTOR 4459 FACTOR VIII	305	RC	85245	CPT				Both			322.35	145.06	17.34	290.12	20.39							Fee Schedule		25.49							Fee Schedule		23.63							Fee Schedule		22.94							Fee Schedule		18.64							Fee Schedule		290.12							Fee Schedule		21.44							Fee Schedule		17.34							Fee Schedule		22.94							Fee Schedule		21.44							Fee Schedule		17.34							Fee Schedule		
RIVASTIGMINE (EXELON) 4.6MG PATCH	250	RC	A9270	CPT				Both			51.45	23.15	0.01	46.31	0.01							Fee Schedule		38.07							Fee Schedule																													46.31							Fee Schedule																																															
RIVASTIGMINE (EXELON) 9.5MG PATCH	250	RC	A9270	CPT				Both			51.45	23.15	0.01	46.31	0.01							Fee Schedule		38.07							Fee Schedule																													46.31							Fee Schedule																																															
RIVASTIGMINE 1.5 MG (EXELON) CAPSULE	250	RC	A9270	CPT				Both			11.81	5.31	0.01	26.38	0.01							Fee Schedule		8.74							Fee Schedule																				22.94							Fee Schedule		10.63							Fee Schedule		26.38							Fee Schedule		21.33							Fee Schedule											26.38							Fee Schedule		21.33							Fee Schedule		
RIVASTIGMINE 4.5 MG (EXELON) CAPSULE	250	RC	A9270	CPT				Both			11.81	5.31	0.01	10.63	0.01							Fee Schedule		8.74							Fee Schedule																													10.63							Fee Schedule																																															
RIVASTIGMINE 6 MG (EXELON) CAPSULE	250	RC						Both			11.81	5.31	5.31	10.63	7.68							Fee Schedule		8.74							Fee Schedule																													10.63							Fee Schedule																																															
RIVASTIGMINE TARTRATE 2 MG/ML SOLN-120ML	250	RC						Both			1203.3	541.49	541.49	1082.97	782.15							Fee Schedule		890.44							Fee Schedule																													1082.97							Fee Schedule																																															
RNA POLYMERASE III AB QUEST 19899	301	RC	83516	CPT				Both			160.92	72.41	10.25	144.83	10.25							Fee Schedule		12.81							Fee Schedule		11.88							Fee Schedule		11.53							Fee Schedule											144.83							Fee Schedule																				11.53							Fee Schedule																				
RNP ANTIBODY 19887	300	RC	86235	CPT				Both			81	36.45	15.94	72.9	15.94							Fee Schedule		19.93							Fee Schedule		18.47							Fee Schedule		17.93							Fee Schedule											72.9							Fee Schedule																				17.93							Fee Schedule																				
ROADRUNNER WIRE GUIDE 0.035/145C G18154	272	RC						Both			147	66.15	66.15	132.3	95.55							Fee Schedule		108.78							Fee Schedule																													132.3							Fee Schedule																																															
ROBAXIN-750 TABS	250	RC						Both			1.58	0.71	0.71	13.26	1.03							Fee Schedule		1.17							Fee Schedule																				11.53							Fee Schedule		1.42							Fee Schedule		13.26							Fee Schedule		10.72							Fee Schedule											13.26							Fee Schedule		10.72							Fee Schedule		
ROBINSON RED CATHETR	272	RC						Both			3.15	1.42	1.42	20.62	2.05							Fee Schedule		2.33							Fee Schedule																				17.93							Fee Schedule		2.84							Fee Schedule		20.62							Fee Schedule		16.67							Fee Schedule											20.62							Fee Schedule		16.67							Fee Schedule		
ROBINUL 0.2 MG/ML	250	RC						Both			5.25	2.36	2.36	4.73	3.41							Fee Schedule		3.89							Fee Schedule																													4.73							Fee Schedule																																															
ROBINUL/1CC	250	RC						Both			4.2	1.89	1.89	3.78	2.73							Fee Schedule		3.11							Fee Schedule																													3.78							Fee Schedule																																															
ROBITUSSIN (GUAIFENSIN):4 OZ	250	RC						Both			5.64	2.54	2.54	5.08	3.67							Fee Schedule		4.17							Fee Schedule																													5.08							Fee Schedule																																															
ROBITUSSIN AC:PER OZ	250	RC						Both			2.84	1.28	1.28	2.56	1.85							Fee Schedule		2.1							Fee Schedule																													2.56							Fee Schedule																																															
ROBITUSSIN DAC SYR	250	RC						Both			6.12	2.75	2.75	5.51	3.98							Fee Schedule		4.53							Fee Schedule																													5.51							Fee Schedule																																															
ROBITUSSIN-DM 4 OZ	250	RC	A9270	CPT				Both			7.5	3.38	0.01	6.75	0.01							Fee Schedule		5.55							Fee Schedule																													6.75							Fee Schedule																																															
ROBITUSSIN-PE:4 OZS	250	RC	A9270	CPT				Both			17.85	8.03	0.01	16.07	0.01							Fee Schedule		13.21							Fee Schedule																													16.07							Fee Schedule																																															
ROBOTIC KNEE BODY STRAP #NON081541	270	RC						Both			7	3.15	3.15	6.3	4.55							Fee Schedule		5.18							Fee Schedule																													6.3							Fee Schedule																																															
ROCEPHIN 1 GM VIAL	636	RC	J0696	CPT				Both			126.11	56.75	0.42	113.5		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	93.32							Fee Schedule		0.42							Fee Schedule																				113.5							Fee Schedule																																															
ROCEPHIN 1GM ADV	636	RC	J0696	CPT				Both			126	56.7	0.42	113.4		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	93.24							Fee Schedule		0.42							Fee Schedule																				113.4							Fee Schedule																																															
ROCEPHIN 2GM ADV	636	RC	J0696	CPT				Both			218.36	98.26	0.42	196.52		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	161.59							Fee Schedule		0.42							Fee Schedule																				196.52							Fee Schedule																																															
ROCURONIUM (ZEMURON) 10 MG/ML-10ML VIAL	250	RC	J3490	CPT				Both			6	2.7	0.38	5.4	3.9							Fee Schedule		4.44							Fee Schedule																				0.4							Fee Schedule		5.4							Fee Schedule		0.46							Fee Schedule		0.38							Fee Schedule											0.46							Fee Schedule		0.38							Fee Schedule		
ROCURONIUM (ZEMURON) 10 MG/ML-5ML VIAL	250	RC	J3490	CPT				Both			6	2.7	0.38	5.4	3.9							Fee Schedule		4.44							Fee Schedule																				0.4							Fee Schedule		5.4							Fee Schedule		0.46							Fee Schedule		0.38							Fee Schedule											0.46							Fee Schedule		0.38							Fee Schedule		
ROCURONIUM 10 MG/ML-10ML SYRINGE	250	RC	A9270	CPT				Both			53.52	24.08	0.01	48.17	0.01							Fee Schedule		39.6							Fee Schedule																				0.4							Fee Schedule		48.17							Fee Schedule		0.46							Fee Schedule		0.38							Fee Schedule											0.46							Fee Schedule		0.38							Fee Schedule		
RODS CABON FIBER 250MM	278	RC						Both			1017.45	457.85	457.85	915.71		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	752.91							Fee Schedule																													915.71							Fee Schedule																																															
RODS CABON FIBER 300MM	278	RC	C1713	CPT				Both			1167.6	525.42	525.42	1050.84		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	864.02							Fee Schedule																													1050.84							Fee Schedule																																															
ROMAZICON 1MG/10ML	250	RC						Both			134.95	60.73	60.73	121.46	87.72							Fee Schedule		99.86							Fee Schedule																													121.46							Fee Schedule																																															
ROMAZICON PER CC	250	RC						Both			13.65	6.14	6.14	12.29	8.87							Fee Schedule		10.1							Fee Schedule																													12.29							Fee Schedule																																															
ROOM AND BOARD 	110	RC						Inpatient			500	225	225	4562	1500							Per Diem		1842							Per Diem									Other	Base Rate DRG Payment								Other	Base Rate DRG Payment								Other 	DRG Base Rate	450							Fee Schedule									Other	DRG Base Rate								Other	DRG Base Rate	4562							Per Diem									Other	DRG Base Rate								Other	DRG Base Rate	
ROOM AND BOARD SCU	200	RC						Inpatient			750	337.5	337.5	4774	2500							Per Diem		1842							Per Diem									Other	Base Rate DRG Payment								Other	Base Rate DRG Payment								Other 	DRG Base Rate	675							Fee Schedule									Other 	DRG Base Rate								Other	DRG Base Rate	4774							Per Diem									Other 	DRG Base Rate								Other	DRG Base Rate	
rOPINIRole 0.25MG (REQUIP) TABLET	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
ROPINIROLE 1 MG TABLET UD	250	RC	A9270	CPT				Both			4.2	1.89	0.01	3.78	0.01							Fee Schedule		3.11							Fee Schedule																													3.78							Fee Schedule																																															
rOPINIRole 1MG (REQUIP) TABLET	250	RC	A9270	CPT				Both			8.4	3.78	0.01	7.56	0.01							Fee Schedule		6.22							Fee Schedule																													7.56							Fee Schedule																																															
ROPIVACAINE 0.2% 200 ML PREMIX (NAROPIN)	636	RC	J2795	CPT				Both			278.1	125.15	0.04	250.29		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	205.79							Fee Schedule		0.04							Fee Schedule																				250.29							Fee Schedule																																															
ROSS FLEX TUBE 12 FR.	272	RC						Both			39.9	17.96	17.96	35.91	25.94							Fee Schedule		29.53							Fee Schedule																													35.91							Fee Schedule																																															
ROSS FLEXIFLO GASTRO TUBE #228	272	RC						Both			213.15	95.92	95.92	191.84	138.55							Fee Schedule		157.73							Fee Schedule																													191.84							Fee Schedule																																															
ROSUVASTATIN  5MG TABLET	250	RC	A9270	CPT				Both			21.43	9.64	0.01	19.29	0.01							Fee Schedule		15.86							Fee Schedule																				0.04							Fee Schedule		19.29							Fee Schedule		0.04							Fee Schedule		0.04							Fee Schedule											0.04							Fee Schedule		0.04							Fee Schedule		
ROSUVASTATIN 10MG TABLET	250	RC	A9270	CPT				Both			21.42	9.64	0.01	19.28	0.01							Fee Schedule		15.85							Fee Schedule																													19.28							Fee Schedule																																															
ROTARIX ORAL SUSPENSION	636	RC	90681	CPT				Both			352.55	158.65	158.65	317.3		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	260.89							Fee Schedule																													317.3							Fee Schedule																																															
ROTATEQ VACCINE	636	RC	90680	CPT				Both			123.14	55.41	55.41	110.83		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	91.12							Fee Schedule																													110.83							Fee Schedule																																															
ROTAVIRUS ANTIGEN 706 STOOL	306	RC	87425	CPT				Both			142.8	64.26	10.66	128.52	10.66							Fee Schedule		13.32							Fee Schedule		12.34							Fee Schedule		11.98							Fee Schedule											128.52							Fee Schedule																				11.98							Fee Schedule																				
ROUND FAST CUTTING BUR 3.2 149	272	RC						Both			105	47.25	47.25	94.5	68.25							Fee Schedule		77.7							Fee Schedule																													94.5							Fee Schedule																																															
RPR WITH REFLEX TITER & FTA 36126	302	RC	86592	CPT				Both			20	9	3.79	18	3.79							Fee Schedule		4.75							Fee Schedule		4.4							Fee Schedule		4.27							Fee Schedule											18							Fee Schedule																				4.27							Fee Schedule																				
RSV NASAL SWAB ID NOW	302	RC	87636	CPT				Both			124.95	56.23	11.14	146.91	81.22							Fee Schedule		142.63							Fee Schedule		146.91							Fee Schedule		142.63							Fee Schedule		11.98							Fee Schedule		112.46							Fee Schedule		13.78							Fee Schedule		11.14							Fee Schedule											13.78							Fee Schedule		11.14							Fee Schedule		
RSV NASAL SWAB SOFIA	302	RC	87807	CPT				Both			124.95	56.23	10.66	112.46	10.66							Fee Schedule		13.32							Fee Schedule		13.49							Fee Schedule		13.1							Fee Schedule											112.46							Fee Schedule																																															
RSV NASAL WASHINGS OR ASPIRATES	302	RC	86171	CPT				Both			124.95	56.23	3.97	112.46	8.9							Fee Schedule		11.12							Fee Schedule		10.31							Fee Schedule		10.01							Fee Schedule		4.27							Fee Schedule		112.46							Fee Schedule		4.91							Fee Schedule		3.97							Fee Schedule		10.01							Fee Schedule		4.91							Fee Schedule		3.97							Fee Schedule		
"RSV, RNA, QUAL PCR 16047"	302	RC	87634	CPT				Both			214.02	96.31	62.4	192.62	62.4							Fee Schedule		77.99							Fee Schedule		72.31							Fee Schedule		70.2							Fee Schedule		142.63							Fee Schedule		192.62							Fee Schedule		164.02							Fee Schedule		132.65							Fee Schedule		70.2							Fee Schedule		164.02							Fee Schedule		132.65							Fee Schedule		
RT- AEROSOL 3 CC LIDOCAINE	412	RC	94640	CPT				Both			283.5	127.58	12.18	286	175							Per Diem		209.79							Fee Schedule											12.53							Fee Schedule		13.1							Fee Schedule		255.15							Fee Schedule		15.07							Fee Schedule		12.18							Fee Schedule		286							Case Rate		15.07							Fee Schedule		12.18							Fee Schedule		
RT- SODIUM CHLORIDE 0.9% INH SOL-UD	250	RC	J7699	CPT				Both			6.3	2.84	2.84	11.51	4.1							Fee Schedule		4.66							Fee Schedule																				10.01							Fee Schedule		5.67							Fee Schedule		11.51							Fee Schedule		9.31							Fee Schedule											11.51							Fee Schedule		9.31							Fee Schedule		
RT- SODIUM CHLORIDE 3%  AEROSOL UD	250	RC	A9270	CPT				Both			6.3	2.84	0.01	80.73	0.01							Fee Schedule		4.66							Fee Schedule																				70.2							Fee Schedule		5.67							Fee Schedule		80.73							Fee Schedule		65.29							Fee Schedule											80.73							Fee Schedule		65.29							Fee Schedule		
"RUBELLA ANTIBODY IGG, IMMUNE STATUS 802"	302	RC	86762	CPT				Both			60	27	12.79	54	12.79							Fee Schedule		15.99							Fee Schedule		14.82							Fee Schedule		14.39							Fee Schedule											54							Fee Schedule																				14.39							Fee Schedule																				
RUBELLA VIRUS IGM AB 4422 SERUM	302	RC	86762	CPT				Both			113.4	51.03	12.79	102.06	12.79							Fee Schedule		15.99							Fee Schedule		14.82							Fee Schedule		14.39							Fee Schedule											102.06							Fee Schedule																				14.39							Fee Schedule																				
RUBEOLA VIRUS IGG AB 964 SERUM	302	RC	86765	CPT				Both			98.7	44.42	11.45	88.83	11.45							Fee Schedule		14.31							Fee Schedule		13.27							Fee Schedule		12.88							Fee Schedule											88.83							Fee Schedule																				12.88							Fee Schedule																				
RUBEOLA VIRUS IGM AB 34256 SERUM	302	RC	86765	CPT				Both			98.7	44.42	11.45	88.83	11.45							Fee Schedule		14.31							Fee Schedule		13.27							Fee Schedule		12.88							Fee Schedule		14.39							Fee Schedule		88.83							Fee Schedule		16.55							Fee Schedule		13.38							Fee Schedule		12.88							Fee Schedule		16.55							Fee Schedule		13.38							Fee Schedule		
RUMI II HANDLE UMH650	272	RC						Both			3744	1684.8	13.38	3369.6	2433.6							Fee Schedule		2770.56							Fee Schedule																				14.39							Fee Schedule		3369.6							Fee Schedule		16.55							Fee Schedule		13.38							Fee Schedule											16.55							Fee Schedule		13.38							Fee Schedule		
RUMI II INTRAUTERINE TIPS BLUE UMB678	272	RC						Both			232	104.4	11.98	208.8	150.8							Fee Schedule		171.68							Fee Schedule																				12.88							Fee Schedule		208.8							Fee Schedule		14.81							Fee Schedule		11.98							Fee Schedule											14.81							Fee Schedule		11.98							Fee Schedule		
RUMI II INTRAUTERINE TIPS GREEN UMG670	272	RC						Both			232	104.4	11.98	208.8	150.8							Fee Schedule		171.68							Fee Schedule																				12.88							Fee Schedule		208.8							Fee Schedule		14.81							Fee Schedule		11.98							Fee Schedule											14.81							Fee Schedule		11.98							Fee Schedule		
RUMI II INTRAUTERINE WHITE TIPS  UMW676	272	RC						Both			232	104.4	104.4	208.8	150.8							Fee Schedule		171.68							Fee Schedule																													208.8							Fee Schedule																																															
RUMI II UTERINE MAIPULATOR 2.5KC-RUMI-25	272	RC						Both			382.2	171.99	171.99	343.98	248.43							Fee Schedule		282.83							Fee Schedule																													343.98							Fee Schedule																																															
RUMI II UTERINE MAIPULATOR 3.5KC-RUMI-35	272	RC						Both			550	247.5	247.5	495	357.5							Fee Schedule		407							Fee Schedule																													495							Fee Schedule																																															
RUMI II UTERINE MANIPULATOR 3 KC-RUMI-30	272	RC						Both			550	247.5	247.5	495	357.5							Fee Schedule		407							Fee Schedule																													495							Fee Schedule																																															
RUPTURE MEMBRANE (ROM PLUS) AMNIOTIC FL	300	RC	84112	CPT				Both			131.25	59.06	59.06	118.13	70.64							Fee Schedule		98.11							Fee Schedule		101.05							Fee Schedule		98.11							Fee Schedule											118.13							Fee Schedule																				98.11							Fee Schedule																				
RUSSELL VIPER VENOM 15780 LT BLUE 2ML FZ	305	RC	85613	CPT				Both			68.25	30.71	8.52	61.43	8.52							Fee Schedule		10.64							Fee Schedule		9.87							Fee Schedule		9.58							Fee Schedule											61.43							Fee Schedule																				9.58							Fee Schedule																				
RUSSELL VIPER VENOM 15780 LT BLUE 2ML FZ	305	RC	85613	CPT				Both			68.25	30.71	8.52	61.43	8.52							Fee Schedule		10.64							Fee Schedule		9.87							Fee Schedule		9.58							Fee Schedule											61.43							Fee Schedule																				9.58							Fee Schedule																				
RUTUSS DE TABS	250	RC	A9270	CPT				Both			4.2	1.89	0.01	112.83	0.01							Fee Schedule		3.11							Fee Schedule																				98.11							Fee Schedule		3.78							Fee Schedule		112.83							Fee Schedule		91.24							Fee Schedule											112.83							Fee Schedule		91.24							Fee Schedule		
RUTUSS TAB	250	RC	A9270	CPT				Both			1.59	0.72	0.01	11.02	0.01							Fee Schedule		1.18							Fee Schedule																				9.58							Fee Schedule		1.43							Fee Schedule		11.02							Fee Schedule		8.91							Fee Schedule											11.02							Fee Schedule		8.91							Fee Schedule		
RX BILIARY STENT SYSTEM #M00545640	278	RC	C1877	CPT				Both			321	144.45	8.91	288.9		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	237.54							Fee Schedule																				9.58							Fee Schedule		288.9							Fee Schedule		11.02							Fee Schedule		8.91							Fee Schedule											11.02							Fee Schedule		8.91							Fee Schedule		
RX BILIARY STENT SYSTEM #M00545690	278	RC	C1877	CPT				Both			220.5	99.23	99.23	198.45		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	163.17							Fee Schedule																													198.45							Fee Schedule																																															
RX CYTOLOGY BRUSH #M00545000	272	RC						Both			328	147.6	147.6	295.2	213.2							Fee Schedule		242.72							Fee Schedule																													295.2							Fee Schedule																																															
RX ERCP CANNULA BALL TIP #M00545780	272	RC						Both			225	101.25	101.25	202.5	146.25							Fee Schedule		166.5							Fee Schedule																													202.5							Fee Schedule																																															
RX LOCK DEVICE & BIOPSY CAP #M00545261	272	RC						Both			29	13.05	13.05	26.1	18.85							Fee Schedule		21.46							Fee Schedule																													26.1							Fee Schedule																																															
RYNATAN TABLETS	250	RC	A9270	CPT				Both			2.93	1.32	0.01	2.64	0.01							Fee Schedule		2.17							Fee Schedule																													2.64							Fee Schedule																																															
SABER HOOK WAND AC4330-01	272	RC						Both			571	256.95	256.95	513.9	371.15							Fee Schedule		422.54							Fee Schedule																													513.9							Fee Schedule																																															
SACCHAROMYCES IGA 10295 1ML SERU	300	RC	86671	CPT				Both			120.75	54.34	10.89	108.68	10.89							Fee Schedule		13.62							Fee Schedule		12.62							Fee Schedule		12.25							Fee Schedule											108.68							Fee Schedule																				12.25							Fee Schedule																				
SACCHAROMYCES IGG 10294  1ML SERU	300	RC	86671	CPT				Both			120.75	54.34	10.89	108.68	10.89							Fee Schedule		13.62							Fee Schedule		12.62							Fee Schedule		12.25							Fee Schedule											108.68							Fee Schedule																				12.25							Fee Schedule																				
SACRUM/COCCYX 2V MIN	320	RC	72220	CPT				Both			315	141.75	15.89	318	15.89							Fee Schedule		19.67							Fee Schedule											16.3							Fee Schedule											283.5							Fee Schedule																				318							Per Diem																				
SAFET T-PIECE RESUS. SM INFANT 87-ST712	270	RC						Both			60	27	11.39	54	39							Fee Schedule		44.4							Fee Schedule																				12.25							Fee Schedule		54							Fee Schedule		14.09							Fee Schedule		11.39							Fee Schedule											14.09							Fee Schedule		11.39							Fee Schedule		
SAFET T-PIECE RESUS. SM NEONATE 87-ST711	270	RC						Both			80	36	11.39	72	52							Fee Schedule		59.2							Fee Schedule																				12.25							Fee Schedule		72							Fee Schedule		14.09							Fee Schedule		11.39							Fee Schedule											14.09							Fee Schedule		11.39							Fee Schedule		
SAFET T-PIECE RESUSCITATOR #87-ST713	270	RC						Both			69	31.05	31.05	62.1	44.85							Fee Schedule		51.06							Fee Schedule																													62.1							Fee Schedule																																															
SAFETY INTIMA CATHALON 20X1 1/4	272	RC						Both			10.5	4.73	4.73	9.45	6.83							Fee Schedule		7.77							Fee Schedule																													9.45							Fee Schedule																																															
SAFETY LOCK VACUT 21X3/4 BD#367281 H.H.	272	RC						Both			3.15	1.42	1.42	2.84	2.05							Fee Schedule		2.33							Fee Schedule																													2.84							Fee Schedule																																															
SAFETY LOCK VACUTAINER 25 3/4 BD#367285H	272	RC						Both			3.15	1.42	1.42	2.84	2.05							Fee Schedule		2.33							Fee Schedule																													2.84							Fee Schedule																																															
SAFETY LOCK VACUTAINER 25 3/4 BD#367298	272	RC						Both			3.15	1.42	1.42	2.84	2.05							Fee Schedule		2.33							Fee Schedule																													2.84							Fee Schedule																																															
SAFETY SCALPEL #10 372610	270	RC	A4649	CPT				Both			5	2.25	2.25	4.5	3.25							Fee Schedule		3.7							Fee Schedule																													4.5							Fee Schedule																																															
SAFETY SCALPEL #11 372611	272	RC						Both			5	2.25	2.25	4.5	3.25							Fee Schedule		3.7							Fee Schedule																													4.5							Fee Schedule																																															
SAFETY SCALPEL #15 372615	270	RC	A4649	CPT				Both			5	2.25	2.25	4.5	3.25							Fee Schedule		3.7							Fee Schedule																													4.5							Fee Schedule																																															
SAGITAL BLADE 190	272	RC						Both			123.9	55.76	55.76	111.51	80.54							Fee Schedule		91.69							Fee Schedule																													111.51							Fee Schedule																																															
SAGITAL BLADE 55	272	RC						Both			123.9	55.76	55.76	111.51	80.54							Fee Schedule		91.69							Fee Schedule																													111.51							Fee Schedule																																															
SALICYLATE	300	RC	80307	CPT				Both			37.8	17.01	17.01	64.65	51.72							Fee Schedule		64.65							Fee Schedule		64							Fee Schedule		62.14							Fee Schedule											34.02							Fee Schedule																				62.14							Fee Schedule																				
SALIVA SUBSTITUTE	250	RC	A9270	CPT				Both			22.05	9.92	0.01	19.85	0.01							Fee Schedule		16.32							Fee Schedule																													19.85							Fee Schedule																																															
SALMETEROL 50 MCG (SEREVENT) DISK  INH	636	RC	J3535	CPT				Both			332.29	149.53	149.53	299.06		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	245.89							Fee Schedule																													299.06							Fee Schedule																																															
SALMONELLA AND SHIGELLA CULT 10019	302	RC	87045	CPT				Both			44.82	20.17	8.4	71.46	8.4							Fee Schedule		10.49							Fee Schedule		9.72							Fee Schedule		9.44							Fee Schedule		62.14							Fee Schedule		40.34							Fee Schedule		71.46							Fee Schedule		57.79							Fee Schedule		9.44							Fee Schedule		71.46							Fee Schedule		57.79							Fee Schedule		
SALMONELLA TOTAL AB EIA 10582 1ML SERUM	302	RC	86768	CPT				Both			73.5	33.08	11.72	66.15	11.72							Fee Schedule		14.65							Fee Schedule		13.59							Fee Schedule		13.19							Fee Schedule											66.15							Fee Schedule																				13.19							Fee Schedule																				
SALSALATE 500 MG TABLET UD	250	RC	A9270	CPT				Both			4.2	1.89	0.01	3.78	0.01							Fee Schedule		3.11							Fee Schedule																													3.78							Fee Schedule																																															
SAM SPLINT 4 1/2X36  661121	274	RC	A4570	CPT				Both			52	23.4	8.78	46.8		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	38.48							Fee Schedule											17.85							Fee Schedule		9.44							Fee Schedule		46.8							Fee Schedule		10.86							Fee Schedule		8.78							Fee Schedule											10.86							Fee Schedule		8.78							Fee Schedule		
SANDIMMUNE 100 MG (CYCLOSPORINE) CAP	636	RC	J7515	CPT				Both			21.74	9.78	0.57	19.57		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	16.09							Fee Schedule		0.57							Fee Schedule											13.19							Fee Schedule		19.57							Fee Schedule		15.17							Fee Schedule		12.27							Fee Schedule											15.17							Fee Schedule		12.27							Fee Schedule		
SANDIMMUNE 50 MG TABS (CYCLOSPORINE)	636	RC	J7515	CPT				Both			8.35	3.76	0.57	7.52		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	6.18							Fee Schedule		0.57							Fee Schedule																				7.52							Fee Schedule																																															
SANDIMMUNE 50 MG/ML- 5ML AMP	636	RC	J7516	CPT				Both			91.35	41.11	41.11	82.22		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	67.6							Fee Schedule		77.92							Fee Schedule																				82.22							Fee Schedule																																															
SANDOSTATIN   50 MCG/ML	636	RC	J2353	CPT				Both			17.54	7.89	0.51	205.15		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	188.35							Fee Schedule		205.15							Fee Schedule											0.55							Fee Schedule		15.79							Fee Schedule		0.63							Fee Schedule		0.51							Fee Schedule											0.63							Fee Schedule		0.51							Fee Schedule		
SAPHNELO IV SOLN 300MG/ 100ML NS IVPB	636	RC	J0491	CPT				Both			19880.1	8946.05	0.51	17892.09		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	18.31							Fee Schedule		18.89							Fee Schedule											0.55							Fee Schedule		17892.09							Fee Schedule		0.63							Fee Schedule		0.51							Fee Schedule											0.63							Fee Schedule		0.51							Fee Schedule		
SAPHNELO IV SOLN 300MG/2ML VIAL	636	RC	J0491	CPT				Both			19880.1	8946.05	18.31	17892.09		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	18.31							Fee Schedule		18.89							Fee Schedule											75.65							Fee Schedule		17892.09							Fee Schedule		87							Fee Schedule		70.35							Fee Schedule											87							Fee Schedule		70.35							Fee Schedule		
SARMIENTO CUFF SHOULDER BRACE (HANGER CL	274	RC	L3980	CPT				Both			1583.4	712.53	185.23	1425.06		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1171.72							Fee Schedule		358.06							Fee Schedule		274.53							Fee Schedule		199.17							Fee Schedule		1425.06							Fee Schedule		229.05							Fee Schedule		185.23							Fee Schedule											229.05							Fee Schedule		185.23							Fee Schedule		
SARMIENTO CUFF SOCK (HANGER CL	274	RC	L3995	CPT				Both			132.3	59.54	17.05	119.07		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	97.9							Fee Schedule		39.6							Fee Schedule		30.38							Fee Schedule		18.34							Fee Schedule		119.07							Fee Schedule		21.09							Fee Schedule		17.05							Fee Schedule											21.09							Fee Schedule		17.05							Fee Schedule		
"SARS COV/ INFLUENZA  A/B COMBO, SOFIA"	300	RC	87428	CPT				Both			260	117	17.05	234	169							Fee Schedule		63.59							Fee Schedule		72.4							Fee Schedule		70.29							Fee Schedule		18.34							Fee Schedule		234							Fee Schedule		21.09							Fee Schedule		17.05							Fee Schedule											21.09							Fee Schedule		17.05							Fee Schedule		
"SARS COV-2 AG NASAL SWAB, SOFIA"	300	RC	87426	CPT				Both			45	20.25	20.25	399.77	29.25							Fee Schedule		35.33							Fee Schedule		36.39							Fee Schedule		35.33							Fee Schedule		347.63							Fee Schedule		40.5							Fee Schedule		399.77							Fee Schedule		323.3							Fee Schedule		35.33							Fee Schedule		399.77							Fee Schedule		323.3							Fee Schedule		
"SARS COVID 19, INFLU A & B, NAAT 31688"	300	RC	87636	CPT				Both			501	225.45	35.76	450.9	325.65							Fee Schedule		142.63							Fee Schedule		146.91							Fee Schedule		142.63							Fee Schedule		38.45							Fee Schedule		450.9							Fee Schedule		44.22							Fee Schedule		35.76							Fee Schedule											44.22							Fee Schedule		35.76							Fee Schedule		
SARS-COV-2 SPECIMEN COLLECTION	300	RC	87635	CPT				Both			225	101.25	51.31	202.5	146.25							Fee Schedule		51.31							Fee Schedule		52.85							Fee Schedule		51.31							Fee Schedule		70.29							Fee Schedule		202.5							Fee Schedule		80.83							Fee Schedule		65.37							Fee Schedule		51.31							Fee Schedule		80.83							Fee Schedule		65.37							Fee Schedule		
SARS-COV-2 TO KNOXVILLE INTEGERITY LAB	310	RC	87635	CPT				Both			115.5	51.98	32.86	103.95	75.08							Fee Schedule		51.31							Fee Schedule		52.85							Fee Schedule		51.31							Fee Schedule		35.33							Fee Schedule		103.95							Fee Schedule		40.63							Fee Schedule		32.86							Fee Schedule											40.63							Fee Schedule		32.86							Fee Schedule		
"SARS-CoV-2 TOT AB, SPIKE, SEM QUAN 39820"	301	RC	86769	CPT				Both			195	87.75	42.13	175.5	126.75							Fee Schedule		42.13							Fee Schedule		43.39							Fee Schedule		42.13							Fee Schedule		142.63							Fee Schedule		175.5							Fee Schedule		164.02							Fee Schedule		132.65							Fee Schedule		42.13							Fee Schedule		164.02							Fee Schedule		132.65							Fee Schedule		
SATCHEL SHEET  59-0803NSO	271	RC						Both			56.7	25.52	25.52	59.01	36.86							Fee Schedule		41.96							Fee Schedule																				51.31							Fee Schedule		51.03							Fee Schedule		59.01							Fee Schedule		47.72							Fee Schedule											59.01							Fee Schedule		47.72							Fee Schedule		
SCALPEL BLADE # 12  371112  (SENECA)	272	RC						Both			4.02	1.81	1.81	59.01	2.61							Fee Schedule		2.97							Fee Schedule																				51.31							Fee Schedule		3.62							Fee Schedule		59.01							Fee Schedule		47.72							Fee Schedule											59.01							Fee Schedule		47.72							Fee Schedule		
SCALPEL BLADE # 20 D6206	272	RC						Both			2.1	0.95	0.95	48.45	1.37							Fee Schedule		1.55							Fee Schedule																				42.13							Fee Schedule		1.89							Fee Schedule		48.45							Fee Schedule		39.18							Fee Schedule											48.45							Fee Schedule		39.18							Fee Schedule		
SCALPEL OR BLADE #10 D6201 (DEROYAL)	270	RC						Both			1	0.45	0.45	0.9	0.65							Fee Schedule		0.74							Fee Schedule																													0.9							Fee Schedule																																															
SCALPEL OR BLADE #11 D6203 (DEROYAL)	272	RC						Both			1	0.45	0.45	0.9	0.65							Fee Schedule		0.74							Fee Schedule																													0.9							Fee Schedule																																															
SCALPEL OR BLADE #15 D6205 (DEROYAL)	272	RC						Both			1	0.45	0.45	0.9	0.65							Fee Schedule		0.74							Fee Schedule																													0.9							Fee Schedule																																															
SCAPELS	272	RC						Both			4.2	1.89	1.89	3.78	2.73							Fee Schedule		3.11							Fee Schedule																													3.78							Fee Schedule																																															
SCAPULA LT	320	RC	73010	CPT				Both			315	141.75	15.04	318	17.35							Fee Schedule		20.65							Fee Schedule											15.04							Fee Schedule											283.5							Fee Schedule																				318							Per Diem																				
SCAPULA RT	320	RC	73010	CPT				Both			315	141.75	15.04	318	17.35							Fee Schedule		20.65							Fee Schedule											15.04							Fee Schedule											283.5							Fee Schedule																				318							Per Diem																				
SCHANZ SCREW SELF DRILLING 5.0	278	RC						Both			164.85	74.18	74.18	148.37		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	121.99							Fee Schedule																													148.37							Fee Schedule																																															
SCHISTOSOMA AB IgG 34306  1ML SERUM FRZ	302	RC	86682	CPT				Both			150.15	67.57	11.56	135.14	11.56							Fee Schedule		14.45							Fee Schedule		13.4							Fee Schedule		13.01							Fee Schedule											135.14							Fee Schedule																				13.01							Fee Schedule																				
SCLERODERMA ANTIBODY 4942 SERUM	300	RC	86235	CPT				Both			170.1	76.55	15.94	153.09	15.94							Fee Schedule		19.93							Fee Schedule		18.47							Fee Schedule		17.93							Fee Schedule											153.09							Fee Schedule																				17.93							Fee Schedule																				
SCOTCH CAST 2  BLACK #82002A	274	RC	A4590	CPT				Both			6	2.7	2.7	24.09		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	4.44							Fee Schedule											24.09							Fee Schedule											5.4							Fee Schedule																																															
SCOTCH CAST 2  BLUE	274	RC	A4590	CPT				Both			6	2.7	2.7	24.09		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	4.44							Fee Schedule											24.09							Fee Schedule		13.01							Fee Schedule		5.4							Fee Schedule		14.96							Fee Schedule		12.1							Fee Schedule											14.96							Fee Schedule		12.1							Fee Schedule		
SCOTCH CAST 2  GREEN	274	RC	A4590	CPT				Both			6	2.7	2.7	24.09		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	4.44							Fee Schedule											24.09							Fee Schedule		17.93							Fee Schedule		5.4							Fee Schedule		20.62							Fee Schedule		16.67							Fee Schedule											20.62							Fee Schedule		16.67							Fee Schedule		
SCOTCH CAST 2  LTBLUE	274	RC	A4590	CPT				Both			7.35	3.31	3.31	24.09		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	5.44							Fee Schedule											24.09							Fee Schedule											6.62							Fee Schedule																																															
SCOTCH CAST 2  ORANGE	274	RC	A4590	CPT				Both			5.22	2.35	2.35	24.09		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	3.86							Fee Schedule											24.09							Fee Schedule											4.7							Fee Schedule																																															
SCOTCH CAST 2  PINK	274	RC	A4590	CPT				Both			6	2.7	2.7	24.09		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	4.44							Fee Schedule											24.09							Fee Schedule											5.4							Fee Schedule																																															
SCOTCH CAST 2  PURPLE	274	RC	A4590	CPT				Both			5.25	2.36	2.36	24.09		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	3.89							Fee Schedule											24.09							Fee Schedule											4.73							Fee Schedule																																															
SCOTCH CAST 2  RED #82002R	274	RC	A4590	CPT				Both			5.2	2.34	2.34	24.09		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	3.85							Fee Schedule											24.09							Fee Schedule											4.68							Fee Schedule																																															
SCOTCH CAST 2  WHITE	274	RC	A4590	CPT				Both			7.35	3.31	3.31	24.09		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	5.44							Fee Schedule											24.09							Fee Schedule											6.62							Fee Schedule																																															
SCOTCH CAST 3  BLACK	274	RC	A4590	CPT				Both			7	3.15	3.15	24.09		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	5.18							Fee Schedule											24.09							Fee Schedule											6.3							Fee Schedule																																															
SCOTCH CAST 3  BLUE	274	RC	A4590	CPT				Both			7	3.15	3.15	24.09		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	5.18							Fee Schedule											24.09							Fee Schedule											6.3							Fee Schedule																																															
SCOTCH CAST 3  GREEN	274	RC	A4590	CPT				Both			7	3.15	3.15	24.09		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	5.18							Fee Schedule											24.09							Fee Schedule											6.3							Fee Schedule																																															
SCOTCH CAST 3  LIGHT BLUE	274	RC	A4590	CPT				Both			8.4	3.78	3.78	24.09		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	6.22							Fee Schedule											24.09							Fee Schedule											7.56							Fee Schedule																																															
SCOTCH CAST 3  ORANGE	274	RC	A4590	CPT				Both			7	3.15	3.15	24.09		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	5.18							Fee Schedule											24.09							Fee Schedule											6.3							Fee Schedule																																															
SCOTCH CAST 3  PINK	274	RC	A4590	CPT				Both			6	2.7	2.7	24.09		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	4.44							Fee Schedule											24.09							Fee Schedule											5.4							Fee Schedule																																															
SCOTCH CAST 3  PURPLE	274	RC	A4590	CPT				Both			7	3.15	3.15	24.09		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	5.18							Fee Schedule											24.09							Fee Schedule											6.3							Fee Schedule																																															
SCOTCH CAST 3  RED	274	RC	A4590	CPT				Both			7	3.15	3.15	24.09		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	5.18							Fee Schedule											24.09							Fee Schedule											6.3							Fee Schedule																																															
SCOTCH CAST 4  BLACK	274	RC	A4590	CPT				Both			9	4.05	4.05	24.09		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	6.66							Fee Schedule											24.09							Fee Schedule											8.1							Fee Schedule																																															
SCOTCH CAST 4  BLUE	274	RC	A4590	CPT				Both			9.45	4.25	4.25	24.09		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	6.99							Fee Schedule											24.09							Fee Schedule											8.51							Fee Schedule																																															
SCOTCH CAST 4  GREEN	274	RC	A4590	CPT				Both			9	4.05	4.05	24.09		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	6.66							Fee Schedule											24.09							Fee Schedule											8.1							Fee Schedule																																															
SCOTCH CAST 4  ORANGE *DISC*	274	RC	A4590	CPT				Both			9.45	4.25	4.25	24.09		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	6.99							Fee Schedule											24.09							Fee Schedule											8.51							Fee Schedule																																															
SCOTCH CAST 4  PINK	274	RC	A4590	CPT				Both			9	4.05	4.05	24.09		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	6.66							Fee Schedule											24.09							Fee Schedule											8.1							Fee Schedule																																															
SCOTCH CAST 4  PURPLE	274	RC	A4590	CPT				Both			9	4.05	4.05	24.09		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	6.66							Fee Schedule											24.09							Fee Schedule											8.1							Fee Schedule																																															
SCOTCH CAST 4  RED	274	RC	A4590	CPT				Both			9	4.05	4.05	24.09		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	6.66							Fee Schedule											24.09							Fee Schedule											8.1							Fee Schedule																																															
SCOTCH CAST 4  WHITE	274	RC	A4590	CPT				Both			9.45	4.25	4.25	24.09		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	6.99							Fee Schedule											24.09							Fee Schedule											8.51							Fee Schedule																																															
SCREW 1020-85	278	RC						Both			259.35	116.71	116.71	233.42		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	191.92							Fee Schedule																													233.42							Fee Schedule																																															
SCREW BIOSURE REGEN. 8MMX20MM 72204398	278	RC	C1713	CPT				Both			834.75	375.64	375.64	751.28		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	617.72							Fee Schedule																													751.28							Fee Schedule																																															
SCREW BIOSURE REGEN. 9MMX25MM 72204404	278	RC	C1713	CPT				Both			834.75	375.64	375.64	751.28		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	617.72							Fee Schedule																													751.28							Fee Schedule																																															
SCREW CAP ADAPTER	272	RC						Both			7.35	3.31	3.31	6.62	4.78							Fee Schedule		5.44							Fee Schedule																													6.62							Fee Schedule																																															
SCROTAL SUPPORT	271	RC						Both			21	9.45	9.45	18.9	13.65							Fee Schedule		15.54							Fee Schedule																													18.9							Fee Schedule																																															
SCROTAL SUPPORT LARGE SA1503L	270	RC						Both			38	17.1	17.1	34.2	24.7							Fee Schedule		28.12							Fee Schedule																													34.2							Fee Schedule																																															
SCROTAL SUPPORT MEDIUM 0910-02	270	RC						Both			16	7.2	7.2	14.4	10.4							Fee Schedule		11.84							Fee Schedule																													14.4							Fee Schedule																																															
SCROTAL SUPPORT SMALL 0910-01	270	RC						Both			15	6.75	6.75	13.5	9.75							Fee Schedule		11.1							Fee Schedule																													13.5							Fee Schedule																																															
SCROTAL SUPPORT XLARGE 1910-04	270	RC						Both			15	6.75	6.75	13.5	9.75							Fee Schedule		11.1							Fee Schedule																													13.5							Fee Schedule																																															
SEAMGUARD STAPLE REINFORCEMENT SGS021R	278	RC	C1781	CPT				Both			544.95	245.23	245.23	490.46		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	403.26							Fee Schedule																													490.46							Fee Schedule																																															
SECONAL 100 MG CAP	250	RC	A9270	CPT				Both			1.58	0.71	0.01	1.42	0.01							Fee Schedule		1.17							Fee Schedule																													1.42							Fee Schedule																																															
SECONDARY SET #2C7461	272	RC						Both			3	1.35	1.35	2.7	1.95							Fee Schedule		2.22							Fee Schedule																													2.7							Fee Schedule																																															
SECRETIN (CHIROSTIM) 16MCG VIAL	636	RC	J2850	CPT				Both			1653.75	744.19	41.31	1488.38		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	41.31							Fee Schedule		41.65							Fee Schedule																				1488.38							Fee Schedule																																															
SECURA ANTIFUNGAL CREAM 3.25OZ #59432900	272	RC	A9150	CPT				Both			10	4.5	1.7	9	1.7							Fee Schedule		7.4							Fee Schedule																													9							Fee Schedule																																															
SECURE CATH	271	RC						Both			5.25	2.36	2.36	4.73	3.41							Fee Schedule		3.89							Fee Schedule																													4.73							Fee Schedule																																															
SED RATE WESTERGREN	305	RC	85652	CPT				Both			90.3	40.64	2.4	81.27	2.4							Fee Schedule		3							Fee Schedule		2.78							Fee Schedule		2.7							Fee Schedule		40.44							Fee Schedule		81.27							Fee Schedule		46.5							Fee Schedule		37.61							Fee Schedule		2.7							Fee Schedule		46.5							Fee Schedule		37.61							Fee Schedule		
OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITH CC					818	DRG		Inpatient			9248.98	4162.04	4162.04	4162.04							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period	
OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITHOUT CC/M					819	DRG		Inpatient			20771.32	9347.09	9347.09	9347.09							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period				3851.97	3851.97	3851.97	1 through 10									0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period	
SELDANE 60 MG TAB	250	RC	A9270	CPT				Both			2.57	1.16	0.01	3.11	0.01							Fee Schedule		1.9							Fee Schedule																				2.7							Fee Schedule		2.31							Fee Schedule		3.11							Fee Schedule		2.51							Fee Schedule											3.11							Fee Schedule		2.51							Fee Schedule		
SELEGILINE 5 MG CAPSULE UD	250	RC	A9270	CPT				Both			9.03	4.06	0.01	8.13	0.01							Fee Schedule		6.68							Fee Schedule																													8.13							Fee Schedule																																															
SELENIUM 16866 URINE 24HR	301	RC	84255	CPT				Both			105	47.25	22.69	94.5	22.69							Fee Schedule		28.37							Fee Schedule		26.3							Fee Schedule		25.53							Fee Schedule											94.5							Fee Schedule																				25.53							Fee Schedule																				
SELENIUM 5507 SERUM ROYAL BLUE 2ML	301	RC	84255	CPT				Both			105	47.25	22.69	94.5	22.69							Fee Schedule		28.37							Fee Schedule		26.3							Fee Schedule		25.53							Fee Schedule											94.5							Fee Schedule																				25.53							Fee Schedule																				
SELF TAP SCREWS	278	RC						Both			35.7	16.07	16.07	32.13		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	26.42							Fee Schedule																													32.13							Fee Schedule																																															
SELLA	320	RC	70240	CPT				Both			315	141.75	11.95	318	17.05							Fee Schedule		19.67							Fee Schedule											11.95							Fee Schedule		25.53							Fee Schedule		283.5							Fee Schedule		29.36							Fee Schedule		23.74							Fee Schedule		318							Per Diem		29.36							Fee Schedule		23.74							Fee Schedule		
SELSUN BLUE SHAMPOO:4 OZS.	250	RC	A9270	CPT				Both			10.99	4.95	0.01	29.36	0.01							Fee Schedule		8.13							Fee Schedule																				25.53							Fee Schedule		9.89							Fee Schedule		29.36							Fee Schedule		23.74							Fee Schedule											29.36							Fee Schedule		23.74							Fee Schedule		
SENNA-LAX (SENOKOT) TABLET	250	RC	A9270	CPT				Both			4.2	1.89	0.01	3.78	0.01							Fee Schedule		3.11							Fee Schedule																													3.78							Fee Schedule																																															
SENNA-S (SENOKOT-S) TABLET	250	RC	A9270	CPT				Both			5.25	2.36	0.01	4.73	0.01							Fee Schedule		3.89							Fee Schedule																													4.73							Fee Schedule																																															
SENSA HEMOCCULT TESTS #SK-64151	270	RC						Both			2.1	0.95	0.95	1.89	1.37							Fee Schedule		1.55							Fee Schedule																													1.89							Fee Schedule																																															
SENSICARE PROTECTANT 5OZ 413587	270	RC	A6250	CPT				Both			13	5.85	0.03	11.7	0.03							Fee Schedule		9.62							Fee Schedule																													11.7							Fee Schedule																																															
SENSOR NITINOL GUIDEWIRE #M0066703051	272	RC	C1769	CPT				Both			134	60.3	60.3	154.26	154.26							Fee Schedule		99.16							Fee Schedule																													120.6							Fee Schedule																																															
SENSORCAINE 0.25% / EPI:30 ML MPF	250	RC	J0665	CPT				Both			43.56	19.6	0.01	39.2	28.31							Fee Schedule		32.23							Fee Schedule		0.01							Fee Schedule																				39.2							Fee Schedule																																															
SENSORCAINE 0.25% 10 ML SDV/MPF	250	RC	J0665	CPT				Both			8.52	3.83	0.01	7.67	5.54							Fee Schedule		6.3							Fee Schedule		0.01							Fee Schedule																				7.67							Fee Schedule																																															
SENSORCAINE 0.25% mpf- 10ML SDV	250	RC						Both			5.25	2.36	2.36	4.73	3.41							Fee Schedule		3.89							Fee Schedule																													4.73							Fee Schedule																																															
SENSORCAINE 0.25%/EPI.10 ML MPF	250	RC	J0665	CPT				Both			27.54	12.39	0.01	24.79	17.9							Fee Schedule		20.38							Fee Schedule		0.01							Fee Schedule											0.01							Fee Schedule		24.79							Fee Schedule		0.01							Fee Schedule		0.01							Fee Schedule											0.01							Fee Schedule		0.01							Fee Schedule		
SENSORCAINE 0.5%/EPI 1:200000 SDPF 10ML	250	RC	J0665	CPT				Both			24.54	11.04	0.01	22.09	15.95							Fee Schedule		18.16							Fee Schedule		0.01							Fee Schedule											0.01							Fee Schedule		22.09							Fee Schedule		0.01							Fee Schedule		0.01							Fee Schedule											0.01							Fee Schedule		0.01							Fee Schedule		
SENTRANT INTRODUCER SHEATH SENSH1228W	272	RC	C1769	CPT				Both			477	214.65	154.26	429.3	154.26							Fee Schedule		352.98							Fee Schedule																													429.3							Fee Schedule																																															
SENTRANT INTRODUCER SHEATH SENSH1264W	272	RC	C1769	CPT				Both			1050	472.5	0.01	945	154.26							Fee Schedule		777							Fee Schedule																				0.01							Fee Schedule		945							Fee Schedule		0.01							Fee Schedule		0.01							Fee Schedule											0.01							Fee Schedule		0.01							Fee Schedule		
SENTRANT INTRODUCER SHEATH SENSH1428W	272	RC	C1769	CPT				Both			630	283.5	0.01	567	154.26							Fee Schedule		466.2							Fee Schedule																				0.01							Fee Schedule		567							Fee Schedule		0.01							Fee Schedule		0.01							Fee Schedule											0.01							Fee Schedule		0.01							Fee Schedule		
SENTRANT INTRODUCER SHEATH SENSH1628W	272	RC	C1769	CPT				Both			636	286.2	154.26	572.4	154.26							Fee Schedule		470.64							Fee Schedule																													572.4							Fee Schedule																																															
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLA					827	DRG		Inpatient			37712.94	16970.82	16970.82	16970.82							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period	
OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITH CC					832	DRG		Inpatient			9634.54	4335.54	4335.54	4335.54							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period	
OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITHOUT C					833	DRG		Inpatient			5733.08	2579.89	2579.89	2579.89							0		No services performed during 15 month lookback period. 				1610.66	1610.66	1610.66	1 through 10									0		No services performed during 15 month lookback period				741.04	741.04	741.04	1 through 10									0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback							0		No services provided during 15 month lookback period				2062.61	2062.61	2062.61	1 through 10			
ACUTE LEUKEMIA WITH MCC					834	DRG		Inpatient			74366.98	33465.14	33465.14	33465.14							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period	
SEPTRA 10ML ADV	250	RC						Both			55.48	24.97	24.97	49.93	36.06							Fee Schedule		41.06							Fee Schedule																													49.93							Fee Schedule																																															
SEPTRA IVPB/250 ML D5W	250	RC	J2865	CPT				Both			24.15	10.87	0.04	21.74	15.7							Fee Schedule		17.87							Fee Schedule		0.04							Fee Schedule																				21.74							Fee Schedule																																															
SER-AP-ES TABLETS	250	RC	A9270	CPT				Both			1.58	0.71	0.01	1.42	0.01							Fee Schedule		1.17							Fee Schedule																													1.42							Fee Schedule																																															
SERENTIL 25 MG TAB	250	RC	A9270	CPT				Both			1.97	0.89	0.01	1.77	0.01							Fee Schedule		1.46							Fee Schedule																													1.77							Fee Schedule																																															
SEREVENT INHALER	636	RC	J3535	CPT				Both			94.31	42.44	0.03	84.88		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	69.79							Fee Schedule																				0.04							Fee Schedule		84.88							Fee Schedule		0.04							Fee Schedule		0.03							Fee Schedule											0.04							Fee Schedule		0.03							Fee Schedule		
SEROTONIN 818 BLOOD	301	RC	84260	CPT				Both			176.4	79.38	27.54	158.76	27.54							Fee Schedule		34.43							Fee Schedule		31.91							Fee Schedule		30.98							Fee Schedule											158.76							Fee Schedule																				30.98							Fee Schedule																				
SEROTONIN RELEASE ASSAY 14627 1ML FZ	302	RC	86022	CPT				Both			358.05	161.12	16.33	322.25	16.33							Fee Schedule		20.41							Fee Schedule		18.92							Fee Schedule		18.37							Fee Schedule											322.25							Fee Schedule																				18.37							Fee Schedule																				
SEROTONIN RELEASE ASSAY QUAN 16284 1MLFZ	302	RC	86022	CPT				Both			358.05	161.12	16.33	322.25	16.33							Fee Schedule		20.41							Fee Schedule		18.92							Fee Schedule		18.37							Fee Schedule											322.25							Fee Schedule																				18.37							Fee Schedule																				
SEROTONIN SERUM 29851 FROZEN SP COLL	301	RC	84260	CPT				Both			144.9	65.21	27.54	130.41	27.54							Fee Schedule		34.43							Fee Schedule		31.91							Fee Schedule		30.98							Fee Schedule		30.98							Fee Schedule		130.41							Fee Schedule		35.63							Fee Schedule		28.81							Fee Schedule		30.98							Fee Schedule		35.63							Fee Schedule		28.81							Fee Schedule		
SERTRALINE 25MG (ZOLOFT) TABLET	250	RC	A9270	CPT				Both			9.45	4.25	0.01	21.13	0.01							Fee Schedule		6.99							Fee Schedule																				18.37							Fee Schedule		8.51							Fee Schedule		21.13							Fee Schedule		17.08							Fee Schedule											21.13							Fee Schedule		17.08							Fee Schedule		
SERTRALINE 50MG (ZOLOFT) TABLET	250	RC	A9270	CPT				Both			6.3	2.84	0.01	21.13	0.01							Fee Schedule		4.66							Fee Schedule																				18.37							Fee Schedule		5.67							Fee Schedule		21.13							Fee Schedule		17.08							Fee Schedule											21.13							Fee Schedule		17.08							Fee Schedule		
SERTRALINE ZOLOFT 8871 SERUM	301	RC	80299	CPT				Both			339.15	152.62	13.42	305.24	13.42							Fee Schedule		18.64							Fee Schedule		19.2							Fee Schedule		18.64							Fee Schedule		30.98							Fee Schedule		305.24							Fee Schedule		35.63							Fee Schedule		28.81							Fee Schedule		18.64							Fee Schedule		35.63							Fee Schedule		28.81							Fee Schedule		
SEVOFLURANE 250ML BOTTLE	250	RC						Both			963.9	433.76	433.76	867.51	626.54							Fee Schedule		713.29							Fee Schedule																													867.51							Fee Schedule																																															
SEX HORMONE BINDING GLOBULIN 30740 SER	301	RC	84270	CPT				Both			35	15.75	15.75	31.5	19.32							Fee Schedule		24.15							Fee Schedule		22.38							Fee Schedule		21.73							Fee Schedule											31.5							Fee Schedule																				21.73							Fee Schedule																				
SGOT	301	RC	84450	CPT				Both			54.6	24.57	4.6	49.14	4.6							Fee Schedule		5.75							Fee Schedule		5.34							Fee Schedule		5.18							Fee Schedule		18.64							Fee Schedule		49.14							Fee Schedule		21.44							Fee Schedule		17.34							Fee Schedule		5.18							Fee Schedule		21.44							Fee Schedule		17.34							Fee Schedule		
SGPT	301	RC	84460	CPT				Both			142.8	64.26	4.71	128.52	4.71							Fee Schedule		5.89							Fee Schedule		5.46							Fee Schedule		5.3							Fee Schedule											128.52							Fee Schedule																				5.3							Fee Schedule																				
SHARN LMA#3 MASK LMI-329-300	272	RC						Both			38	17.1	17.1	34.2	24.7							Fee Schedule		28.12							Fee Schedule																				21.73							Fee Schedule		34.2							Fee Schedule		24.99							Fee Schedule		20.21							Fee Schedule											24.99							Fee Schedule		20.21							Fee Schedule		
SHARN LMA#4 MASK LMI-329-400	272	RC						Both			38	17.1	4.82	34.2	24.7							Fee Schedule		28.12							Fee Schedule																				5.18							Fee Schedule		34.2							Fee Schedule		5.96							Fee Schedule		4.82							Fee Schedule											5.96							Fee Schedule		4.82							Fee Schedule		
SHARN LMA#5 MASK LMI-329-500	272	RC						Both			42	18.9	4.93	37.8	27.3							Fee Schedule		31.08							Fee Schedule																				5.3							Fee Schedule		37.8							Fee Schedule		6.1							Fee Schedule		4.93							Fee Schedule											6.1							Fee Schedule		4.93							Fee Schedule		
SHEEPSKIN 30X60	270	RC						Both			33.6	15.12	15.12	30.24	21.84							Fee Schedule		24.86							Fee Schedule																													30.24							Fee Schedule																																															
SHEPARD GROM VENT WR (DAVIS) GYRUS	272	RC						Both			28.35	12.76	12.76	25.52	18.43							Fee Schedule		20.98							Fee Schedule																													25.52							Fee Schedule																																															
SHEPARD GROMMETT EAR TUBE (SMI&NEPH GYRU	278	RC						Both			25.2	11.34	11.34	22.68		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	18.65							Fee Schedule																													22.68							Fee Schedule																																															
SHIGA Toxin EIA w RFX  Ecoli 0157 30264	302	RC	87427	CPT				Both			204.45	92	10.66	184.01	10.66							Fee Schedule		13.32							Fee Schedule		12.34							Fee Schedule		11.98							Fee Schedule											184.01							Fee Schedule																																															
SHILEY CUFFED TRACH KIT 8.0	272	RC	A7520	CPT				Both			199.5	89.78	41.37	179.55	42.75							Fee Schedule		147.63							Fee Schedule		69.69							Fee Schedule		41.37							Fee Schedule											179.55							Fee Schedule																																															
SHILEY DISP.INNER CANNULA #10	272	RC	A7520	CPT				Both			17	7.65	7.65	69.69	42.75							Fee Schedule		12.58							Fee Schedule		69.69							Fee Schedule		41.37							Fee Schedule											15.3							Fee Schedule																																															
SHILEY DISP.INNER CANNULA #4 4DIC	272	RC	A7520	CPT				Both			17	7.65	7.65	69.69	42.75							Fee Schedule		12.58							Fee Schedule		69.69							Fee Schedule		41.37							Fee Schedule		11.98							Fee Schedule		15.3							Fee Schedule		13.78							Fee Schedule		11.14							Fee Schedule											13.78							Fee Schedule		11.14							Fee Schedule		
SHILEY DISP.INNER CANNULA #6 6DIC	272	RC	A7520	CPT				Both			17	7.65	7.65	77.81	42.75							Fee Schedule		12.58							Fee Schedule		69.69							Fee Schedule		41.37							Fee Schedule		67.66							Fee Schedule		15.3							Fee Schedule		77.81							Fee Schedule		62.92							Fee Schedule											77.81							Fee Schedule		62.92							Fee Schedule		
SHILEY DISP.INNER CANNULA #8 8DIC	272	RC	A7520	CPT				Both			16	7.2	7.2	77.81	42.75							Fee Schedule		11.84							Fee Schedule		69.69							Fee Schedule		41.37							Fee Schedule		67.66							Fee Schedule		14.4							Fee Schedule		77.81							Fee Schedule		62.92							Fee Schedule											77.81							Fee Schedule		62.92							Fee Schedule		
SHILEY DIST. EXT. CUFFED TRACH KIT 6.0	272	RC	A7520	CPT				Both			199.5	89.78	41.37	179.55	42.75							Fee Schedule		147.63							Fee Schedule		69.69							Fee Schedule		41.37							Fee Schedule		67.66							Fee Schedule		179.55							Fee Schedule		77.81							Fee Schedule		62.92							Fee Schedule											77.81							Fee Schedule		62.92							Fee Schedule		
SHILEY DIST. EXT. CUFFED TRACH KIT 7.0	272	RC	A7520	CPT				Both			191.1	86	41.37	171.99	42.75							Fee Schedule		141.41							Fee Schedule		69.69							Fee Schedule		41.37							Fee Schedule		67.66							Fee Schedule		171.99							Fee Schedule		77.81							Fee Schedule		62.92							Fee Schedule											77.81							Fee Schedule		62.92							Fee Schedule		
SHILEY DIST. EXT. CUFFED TRACH KIT 8.0	272	RC	A7520	CPT				Both			191.1	86	41.37	171.99	42.75							Fee Schedule		141.41							Fee Schedule		69.69							Fee Schedule		41.37							Fee Schedule		67.66							Fee Schedule		171.99							Fee Schedule		77.81							Fee Schedule		62.92							Fee Schedule											77.81							Fee Schedule		62.92							Fee Schedule		
SHILEY EXT. CUFFED TRACH KIT 80XLTCP	272	RC	A7521	CPT				Both			263	118.35	40.99	236.7	42.35							Fee Schedule		194.62							Fee Schedule		69.05							Fee Schedule		40.99							Fee Schedule		67.66							Fee Schedule		236.7							Fee Schedule		77.81							Fee Schedule		62.92							Fee Schedule											77.81							Fee Schedule		62.92							Fee Schedule		
SHILEY INNER CANNULA 6-0 X-LONG#77100060	272	RC	A7520	CPT				Both			12.6	5.67	5.67	77.81	42.75							Fee Schedule		9.32							Fee Schedule		69.69							Fee Schedule		41.37							Fee Schedule		67.66							Fee Schedule		11.34							Fee Schedule		77.81							Fee Schedule		62.92							Fee Schedule											77.81							Fee Schedule		62.92							Fee Schedule		
SHILEY INNER CANNULA 7-0 X-LONG#70XLTIN	272	RC	A7520	CPT				Both			18.9	8.51	8.51	77.81	42.75							Fee Schedule		13.99							Fee Schedule		69.69							Fee Schedule		41.37							Fee Schedule		67.66							Fee Schedule		17.01							Fee Schedule		77.81							Fee Schedule		62.92							Fee Schedule											77.81							Fee Schedule		62.92							Fee Schedule		
SHILEY INNER CANNULA 8-0 X-LONG#80XLTIN	272	RC	A7520	CPT				Both			15.75	7.09	7.09	77.1	42.75							Fee Schedule		11.66							Fee Schedule		69.69							Fee Schedule		41.37							Fee Schedule		67.04							Fee Schedule		14.18							Fee Schedule		77.1							Fee Schedule		62.35							Fee Schedule											77.1							Fee Schedule		62.35							Fee Schedule		
SHILEY PROX. EXT. CUFFED TRACH KIT 6.0	272	RC	A7521	CPT				Both			199.5	89.78	40.99	179.55	42.35							Fee Schedule		147.63							Fee Schedule		69.05							Fee Schedule		40.99							Fee Schedule		67.66							Fee Schedule		179.55							Fee Schedule		77.81							Fee Schedule		62.92							Fee Schedule											77.81							Fee Schedule		62.92							Fee Schedule		
SHILEY PROX. EXT. CUFFED TRACH KIT 7.0	272	RC	A7521	CPT				Both			241.5	108.68	40.99	217.35	42.35							Fee Schedule		178.71							Fee Schedule		69.05							Fee Schedule		40.99							Fee Schedule		67.66							Fee Schedule		217.35							Fee Schedule		77.81							Fee Schedule		62.92							Fee Schedule											77.81							Fee Schedule		62.92							Fee Schedule		
SHILEY TRAC NONFENESTRATED 10MM	272	RC	A7520	CPT				Both			314	141.3	41.37	282.6	42.75							Fee Schedule		232.36							Fee Schedule		69.69							Fee Schedule		41.37							Fee Schedule		67.66							Fee Schedule		282.6							Fee Schedule		77.81							Fee Schedule		62.92							Fee Schedule											77.81							Fee Schedule		62.92							Fee Schedule		
SHILEY TRAC NONFENESTRATED 4MM	272	RC	A7520	CPT				Both			199.5	89.78	41.37	179.55	42.75							Fee Schedule		147.63							Fee Schedule		69.69							Fee Schedule		41.37							Fee Schedule		67.04							Fee Schedule		179.55							Fee Schedule		77.1							Fee Schedule		62.35							Fee Schedule											77.1							Fee Schedule		62.35							Fee Schedule		
SHILEY TRAC NONFENESTRATED 6MM	272	RC	A7520	CPT				Both			187	84.15	41.37	168.3	42.75							Fee Schedule		138.38							Fee Schedule		69.69							Fee Schedule		41.37							Fee Schedule		67.04							Fee Schedule		168.3							Fee Schedule		77.1							Fee Schedule		62.35							Fee Schedule											77.1							Fee Schedule		62.35							Fee Schedule		
SHILEY TRAC NONFENESTRATED 8MM	272	RC	A7520	CPT				Both			314	141.3	41.37	282.6	42.75							Fee Schedule		232.36							Fee Schedule		69.69							Fee Schedule		41.37							Fee Schedule		67.66							Fee Schedule		282.6							Fee Schedule		77.81							Fee Schedule		62.92							Fee Schedule											77.81							Fee Schedule		62.92							Fee Schedule		
SHILEY TRAC TUBE #6CFS CUFFLESS	272	RC	A7520	CPT				Both			116.55	52.45	41.37	104.9	42.75							Fee Schedule		86.25							Fee Schedule		69.69							Fee Schedule		41.37							Fee Schedule		67.66							Fee Schedule		104.9							Fee Schedule		77.81							Fee Schedule		62.92							Fee Schedule											77.81							Fee Schedule		62.92							Fee Schedule		
SHILEY TRACH TUBE 10MM 10FEN	272	RC	A7520	CPT				Both			344	154.8	41.37	309.6	42.75							Fee Schedule		254.56							Fee Schedule		69.69							Fee Schedule		41.37							Fee Schedule		67.66							Fee Schedule		309.6							Fee Schedule		77.81							Fee Schedule		62.92							Fee Schedule											77.81							Fee Schedule		62.92							Fee Schedule		
SHILEY TRACH TUBE 4MM 4FEN	272	RC	A7520	CPT				Both			312	140.4	41.37	280.8	42.75							Fee Schedule		230.88							Fee Schedule		69.69							Fee Schedule		41.37							Fee Schedule		67.66							Fee Schedule		280.8							Fee Schedule		77.81							Fee Schedule		62.92							Fee Schedule											77.81							Fee Schedule		62.92							Fee Schedule		
SHILEY TRACH TUBE 6MM 6FEN	274	RC	A7520	CPT				Both			313	140.85	41.37	281.7		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	231.62							Fee Schedule		69.69							Fee Schedule		41.37							Fee Schedule		67.66							Fee Schedule		281.7							Fee Schedule		77.81							Fee Schedule		62.92							Fee Schedule											77.81							Fee Schedule		62.92							Fee Schedule		
SHILEY TRACH TUBE 8MM 8FEN	272	RC	A7520	CPT				Both			312	140.4	41.37	280.8	42.75							Fee Schedule		230.88							Fee Schedule		69.69							Fee Schedule		41.37							Fee Schedule		67.66							Fee Schedule		280.8							Fee Schedule		77.81							Fee Schedule		62.92							Fee Schedule											77.81							Fee Schedule		62.92							Fee Schedule		
SHILEY TRACH TUBE HOLDER	272	RC	A7520	CPT				Both			7.35	3.31	3.31	77.81	42.75							Fee Schedule		5.44							Fee Schedule		69.69							Fee Schedule		41.37							Fee Schedule		67.66							Fee Schedule		6.62							Fee Schedule		77.81							Fee Schedule		62.92							Fee Schedule											77.81							Fee Schedule		62.92							Fee Schedule		
SHINGRIX VACCINE INJECTION	636	RC	90750	CPT				Both			172.2	77.49	62.92	154.98		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	127.43							Fee Schedule																				67.66							Fee Schedule		154.98							Fee Schedule		77.81							Fee Schedule		62.92							Fee Schedule											77.81							Fee Schedule		62.92							Fee Schedule		
SHOCKWAVE LITHOTRYPSY BALLOON M5IVL7060	272	RC	C9764	CPT				Both			10395	4677.75	62.92	12148.06	6756.75							Fee Schedule		7692.3							Fee Schedule		12148.06							Fee Schedule											67.66							Fee Schedule		9355.5							Fee Schedule		77.81							Fee Schedule		62.92							Fee Schedule											77.81							Fee Schedule		62.92							Fee Schedule		
SHOCKWAVE M5+ IVL CATHETER #M5PIVL7060	272	RC	C1761	CPT				Both			10350	4657.5	62.92	9315	6727.5							Fee Schedule		7659							Fee Schedule																				67.66							Fee Schedule		9315							Fee Schedule		77.81							Fee Schedule		62.92							Fee Schedule											77.81							Fee Schedule		62.92							Fee Schedule		
SHORT ARM CAST	274	RC	A4580	CPT				Both			23.1	10.4	10.4	23.72		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	17.09							Fee Schedule											23.72							Fee Schedule											20.79							Fee Schedule																																															
SHORT BEVEL WAND #AC2823-01	272	RC						Both			1557	700.65	700.65	13563.36	1012.05							Fee Schedule		1152.18							Fee Schedule																				11794.23							Fee Schedule		1401.3							Fee Schedule		13563.36							Fee Schedule		10968.63							Fee Schedule											13563.36							Fee Schedule		10968.63							Fee Schedule		
SHORT LEG CAST	274	RC	A4580	CPT				Both			34.65	15.59	15.59	31.19		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	25.64							Fee Schedule											23.72							Fee Schedule											31.19							Fee Schedule																																															
SHORTIE AIR WALKER L 79-95447	274	RC	L4361	CPT				Both			134.66	60.6	60.6	348.2		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	99.65							Fee Schedule		348.2							Fee Schedule																				121.19							Fee Schedule																																															
SHORTIE AIR WALKER M 79-95445	274	RC	L4361	CPT				Both			134.66	60.6	60.6	348.2		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	99.65							Fee Schedule		348.2							Fee Schedule																				121.19							Fee Schedule																																															
SHORTIE AIR WALKER S 79-95443	274	RC	L4361	CPT				Both			134.66	60.6	60.6	348.2		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	99.65							Fee Schedule		348.2							Fee Schedule																				121.19							Fee Schedule																																															
SHOULDER LT 1 VIEW	320	RC	73020	CPT				Both			315	141.75	12.11	388.77	12.11							Fee Schedule		14.15							Fee Schedule											13.64							Fee Schedule		338.06							Fee Schedule		283.5							Fee Schedule		388.77							Fee Schedule		314.4							Fee Schedule		318							Per Diem		388.77							Fee Schedule		314.4							Fee Schedule		
SHOULDER LT 3V	320	RC	73030	CPT				Both			315	141.75	16.18	388.77	16.18							Fee Schedule		18.7							Fee Schedule											16.3							Fee Schedule		338.06							Fee Schedule		283.5							Fee Schedule		388.77							Fee Schedule		314.4							Fee Schedule		318							Per Diem		388.77							Fee Schedule		314.4							Fee Schedule		
SHOULDER PACK MEDLINE #DYNJP8401	270	RC						Both			216	97.2	97.2	388.77	140.4							Fee Schedule		159.84							Fee Schedule																				338.06							Fee Schedule		194.4							Fee Schedule		388.77							Fee Schedule		314.4							Fee Schedule											388.77							Fee Schedule		314.4							Fee Schedule		
SHOULDER RT 1 VIEW	320	RC	73020	CPT				Both			315	141.75	12.11	318	12.11							Fee Schedule		14.15							Fee Schedule											13.64							Fee Schedule											283.5							Fee Schedule																				318							Per Diem																				
SHOULDER RT 3V	320	RC	73030	CPT				Both			315	141.75	16.18	318	16.18							Fee Schedule		18.7							Fee Schedule											16.3							Fee Schedule											283.5							Fee Schedule																				318							Per Diem																				
SHOULDER SUSPENSION KIT #72200195	272	RC						Both			1455.3	654.89	654.89	1309.77	945.95							Fee Schedule		1076.92							Fee Schedule																													1309.77							Fee Schedule																																															
SHOULDER SUSPENSION TRAY #DYNJSHOULDER	272	RC						Both			57	25.65	25.65	51.3	37.05							Fee Schedule		42.18							Fee Schedule																													51.3							Fee Schedule																																															
ACUTE LEUKEMIA WITHOUT CC/MCC					836	DRG		Inpatient			38242.85	17209.28	17209.28	17209.28							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period	
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH CC					841	DRG		Inpatient			29253.6	13164.12	13164.12	13164.12							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period				5560.46	5560.46	5560.46	1 through 10									0		No services provided during 15 month lookback							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period	
S-I JOINT	320	RC	72202	CPT				Both			315	141.75	17.71	318	19.09							Fee Schedule		22.92							Fee Schedule											17.71							Fee Schedule											283.5							Fee Schedule																				318							Per Diem																				
SICKLE CELL SCREEN 825 EDTA	305	RC	85660	CPT				Both			27.3	12.29	4.9	24.57	4.9							Fee Schedule		6.12							Fee Schedule		5.68							Fee Schedule		5.51							Fee Schedule											24.57							Fee Schedule																				5.51							Fee Schedule																				
INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH					853	DRG		Inpatient			75009.86	33754.44	33754.44	33754.44							0		No services performed during 15 month lookback period. 				2436.29	2436.29	2436.29	1 through 10						32799.61	32799.61	32799.61	1 through 10						24806.47	24806.47	24806.47	1 through 10									0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period	
INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH					854	DRG		Inpatient			67236.44	30256.4	30256.4	30256.4							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period							0		No services provided during 15 month lookback period				8168.89	8168.89	8168.89	1 through 10									0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period	
SILASTIC 2-WAY FOLEY 14FR 33614 (BD MED)	272	RC						Both			14	6.3	5.12	12.6	9.1							Fee Schedule		10.36							Fee Schedule																				5.51							Fee Schedule		12.6							Fee Schedule		6.34							Fee Schedule		5.12							Fee Schedule											6.34							Fee Schedule		5.12							Fee Schedule		
SILASTIC 2-WAY FOLEY 16FR 33616 (BD MED)	272	RC						Both			14	6.3	6.3	12.6	9.1							Fee Schedule		10.36							Fee Schedule																													12.6							Fee Schedule																																															
SILASTIC 2-WAY FOLEY 18FR 33618 (BD MED)	272	RC						Both			15	6.75	6.75	13.5	9.75							Fee Schedule		11.1							Fee Schedule																													13.5							Fee Schedule																																															
SILASTIC 2-WAY FOLEY 20FR 33620 (BD MED)	272	RC						Both			14	6.3	6.3	12.6	9.1							Fee Schedule		10.36							Fee Schedule																													12.6							Fee Schedule																																															
SILASTIC 2-WAY FOLEY 22FR 33622 (BD MED)	272	RC						Both			14	6.3	6.3	12.6	9.1							Fee Schedule		10.36							Fee Schedule																													12.6							Fee Schedule																																															
SILICONE BALLOON CATHETER #G17472	272	RC	C1725	CPT				Both			120	54	54	108	93.3							Fee Schedule		88.8							Fee Schedule																													108							Fee Schedule																																															
SILK (0) 624H	272	RC						Both			5.25	2.36	2.36	4.73	3.41							Fee Schedule		3.89							Fee Schedule																													4.73							Fee Schedule																																															
SILK 0 424H	272	RC						Both			4	1.8	1.8	3.6	2.6							Fee Schedule		2.96							Fee Schedule																													3.6							Fee Schedule																																															
SILK 0 678G	272	RC						Both			6	2.7	2.7	5.4	3.9							Fee Schedule		4.44							Fee Schedule																													5.4							Fee Schedule																																															
SILK 0 A186H	272	RC						Both			4	1.8	1.8	3.6	2.6							Fee Schedule		2.96							Fee Schedule																													3.6							Fee Schedule																																															
SILK 0 C027D	272	RC						Both			30	13.5	13.5	27	19.5							Fee Schedule		22.2							Fee Schedule																													27							Fee Schedule																																															
SILK 0 K834H	272	RC						Both			5	2.25	2.25	4.5	3.25							Fee Schedule		3.7							Fee Schedule																													4.5							Fee Schedule																																															
SILK 0 SA66G	272	RC						Both			9	4.05	4.05	8.1	5.85							Fee Schedule		6.66							Fee Schedule																													8.1							Fee Schedule																																															
SILK 0 SA86G	272	RC						Both			5.51	2.48	2.48	4.96	3.58							Fee Schedule		4.08							Fee Schedule																													4.96							Fee Schedule																																															
SILK 2.0 423H	272	RC						Both			9.45	4.25	4.25	8.51	6.14							Fee Schedule		6.99							Fee Schedule																													8.51							Fee Schedule																																															
SILK 2.0 A305H	272	RC						Both			8	3.6	3.6	7.2	5.2							Fee Schedule		5.92							Fee Schedule																													7.2							Fee Schedule																																															
SILK 2-0  C012D	272	RC						Both			29	13.05	13.05	26.1	18.85							Fee Schedule		21.46							Fee Schedule																													26.1							Fee Schedule																																															
SILK 2-0 443H	272	RC						Both			5	2.25	2.25	4.5	3.25							Fee Schedule		3.7							Fee Schedule																													4.5							Fee Schedule																																															
SILK 2-0 623H	272	RC						Both			6	2.7	2.7	5.4	3.9							Fee Schedule		4.44							Fee Schedule																													5.4							Fee Schedule																																															
SILK 2-0 623H	272	RC						Both			6	2.7	2.7	5.4	3.9							Fee Schedule		4.44							Fee Schedule																													5.4							Fee Schedule																																															
SILK 2-0 685H	272	RC						Both			7.35	3.31	3.31	6.62	4.78							Fee Schedule		5.44							Fee Schedule																													6.62							Fee Schedule																																															
SILK 2-0 A185H  J&J	272	RC						Both			6	2.7	2.7	5.4	3.9							Fee Schedule		4.44							Fee Schedule																													5.4							Fee Schedule																																															
SILK 2-0 C026D	272	RC						Both			34	15.3	15.3	30.6	22.1							Fee Schedule		25.16							Fee Schedule																													30.6							Fee Schedule																																															
SILK 2-0 ETHICON PERMAHAND C016D	272	RC						Both			32	14.4	14.4	28.8	20.8							Fee Schedule		23.68							Fee Schedule																													28.8							Fee Schedule																																															
SILK 2-0 K833H	272	RC						Both			5	2.25	2.25	4.5	3.25							Fee Schedule		3.7							Fee Schedule																													4.5							Fee Schedule																																															
SILK 2-0 K833H  J&J	272	RC						Both			5	2.25	2.25	4.5	3.25							Fee Schedule		3.7							Fee Schedule																													4.5							Fee Schedule																																															
SILK 2-0 LA55G REEL	272	RC						Both			6	2.7	2.7	5.4	3.9							Fee Schedule		4.44							Fee Schedule																													5.4							Fee Schedule																																															
SILK 3.0 622H	272	RC						Both			5	2.25	2.25	4.5	3.25							Fee Schedule		3.7							Fee Schedule																													4.5							Fee Schedule																																															
SILK 3.0 A304H	272	RC						Both			10	4.5	4.5	9	6.5							Fee Schedule		7.4							Fee Schedule																													9							Fee Schedule																																															
SILK 3.0 A832H	272	RC						Both			9.45	4.25	4.25	8.51	6.14							Fee Schedule		6.99							Fee Schedule																													8.51							Fee Schedule																																															
SILK 3.0 LA54G	272	RC						Both			5.25	2.36	2.36	4.73	3.41							Fee Schedule		3.89							Fee Schedule																													4.73							Fee Schedule																																															
SILK 3-0 684G	272	RC						Both			6	2.7	2.7	5.4	3.9							Fee Schedule		4.44							Fee Schedule																													5.4							Fee Schedule																																															
SILK 3-0 A184H	272	RC						Both			6	2.7	2.7	5.4	3.9							Fee Schedule		4.44							Fee Schedule																													5.4							Fee Schedule																																															
SILK 3-0 C013D	272	RC						Both			29	13.05	13.05	26.1	18.85							Fee Schedule		21.46							Fee Schedule																													26.1							Fee Schedule																																															
SILK 3-0 K832H	272	RC						Both			5	2.25	2.25	4.5	3.25							Fee Schedule		3.7							Fee Schedule																													4.5							Fee Schedule																																															
SILK 4.0 739G	272	RC						Both			8.4	3.78	3.78	7.56	5.46							Fee Schedule		6.22							Fee Schedule																													7.56							Fee Schedule																																															
SILK 4.0 SA63H	272	RC						Both			5.25	2.36	2.36	4.73	3.41							Fee Schedule		3.89							Fee Schedule																													4.73							Fee Schedule																																															
SILK 4-0 683G	272	RC						Both			6	2.7	2.7	5.4	3.9							Fee Schedule		4.44							Fee Schedule																													5.4							Fee Schedule																																															
SILK 4-0 SA73H	272	RC						Both			8.4	3.78	3.78	7.56	5.46							Fee Schedule		6.22							Fee Schedule																													7.56							Fee Schedule																																															
SILK 5.0 1676H	272	RC						Both			9.45	4.25	4.25	8.51	6.14							Fee Schedule		6.99							Fee Schedule																													8.51							Fee Schedule																																															
SILK 6.0 711G	272	RC						Both			7.35	3.31	3.31	6.62	4.78							Fee Schedule		5.44							Fee Schedule																													6.62							Fee Schedule																																															
SILK 6-0 765G	272	RC						Both			40	18	18	36	26							Fee Schedule		29.6							Fee Schedule																													36							Fee Schedule																																															
SILK ER CHARGE	272	RC						Both			8.4	3.78	3.78	7.56	5.46							Fee Schedule		6.22							Fee Schedule																													7.56							Fee Schedule																																															
SILVADENE CREAM 50 GM	250	RC	A9270	CPT				Both			16.54	7.44	0.01	14.89	0.01							Fee Schedule		12.24							Fee Schedule																													14.89							Fee Schedule																																															
SILVASORB GEL 3OZ #MSC9303EP	271	RC	A6248	CPT				Both			78	35.1	14.63	70.2	14.63							Fee Schedule		57.72							Fee Schedule		23.84							Fee Schedule		18.29							Fee Schedule											70.2							Fee Schedule																																															
SILVER NITRATE APPLICATORS	250	RC	A9270	CPT				Both			5.25	2.36	0.01	4.73	0.01							Fee Schedule		3.89							Fee Schedule																													4.73							Fee Schedule																																															
SILVER SULFADIAZINE 1% CREAM-50GM	250	RC	A9270	CPT				Both			16.38	7.37	0.01	14.74	0.01							Fee Schedule		12.12							Fee Schedule																													14.74							Fee Schedule																																															
SILVER SULFADIAZINE CREAM 25 GM	250	RC	A9270	CPT				Both			28.35	12.76	0.01	26.62	0.01							Fee Schedule		20.98							Fee Schedule																				23.15							Fee Schedule		25.52							Fee Schedule		26.62							Fee Schedule		21.53							Fee Schedule											26.62							Fee Schedule		21.53							Fee Schedule		
SILVER SULFADIAZINE CREAM 400GM	250	RC	A9270	CPT				Both			65.61	29.52	0.01	59.05	0.01							Fee Schedule		48.55							Fee Schedule																													59.05							Fee Schedule																																															
SILVERLON DRESSING 4X10 ID-410	272	RC						Both			100	45	45	90	65							Fee Schedule		74							Fee Schedule																													90							Fee Schedule																																															
SILVERLON DRESSING 4X12 ID-412	272	RC						Both			116	52.2	52.2	104.4	75.4							Fee Schedule		85.84							Fee Schedule																													104.4							Fee Schedule																																															
SIMETHICONE 80MG (MYLICON) TABLET	250	RC	A9270	CPT				Both			3.15	1.42	0.01	2.84	0.01							Fee Schedule		2.33							Fee Schedule																													2.84							Fee Schedule																																															
SIMPLASTIC 3-WAY 30ML FOLEY 22FR	272	RC						Both			56	25.2	25.2	50.4	36.4							Fee Schedule		41.44							Fee Schedule																													50.4							Fee Schedule																																															
POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDU					857	DRG		Inpatient			31395.65	14128.04	14128.04	14128.04							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period	
POSTOPERATIVE AND POST-TRAUMATIC INFECTIONS WITHOUT MCC					863	DRG		Inpatient			24816.22	11167.3	11167.3	11167.3				9462.73	9462.73	9462.73	1 through 10						1729.95	1729.95	1729.95	1 through 10									0		No services performed during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback				7643.58	7643.58	7643.58	1 through 10						3909.75	3909.75	3909.75	1 through 10			
FEVER AND INFLAMMATORY CONDITIONS					864	DRG		Inpatient			17145.6	7715.52	7715.52	7715.52							0		No services performed during 15 month lookback period. 				2516.18	2516.18	2516.18	1 through 10									0		No services performed during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period	
SIMVASTATIN 10MG (ZOCOR) TABLET	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
SIMVASTATIN 20MG (ZOCOR) TABLET	250	RC	A9270	CPT				Both			15.75	7.09	0.01	14.18	0.01							Fee Schedule		11.66							Fee Schedule																													14.18							Fee Schedule																																															
SIMVASTATIN 40MG (ZOCOR) TABLET	250	RC	A9270	CPT				Both			18.9	8.51	0.01	17.01	0.01							Fee Schedule		13.99							Fee Schedule																													17.01							Fee Schedule																																															
SINEMET 3388 2 ML SERUM FROZEN	301	RC	80299	CPT				Both			351.75	158.29	13.42	316.58	13.42							Fee Schedule		18.64							Fee Schedule		19.2							Fee Schedule		18.64							Fee Schedule											316.58							Fee Schedule																				18.64							Fee Schedule																				
SINEMET 3388 SER 4ML FRZ MAN REQ TO NMS	301	RC	80299	CPT				Both			298.2	134.19	13.42	268.38	13.42							Fee Schedule		18.64							Fee Schedule		19.2							Fee Schedule		18.64							Fee Schedule											268.38							Fee Schedule																				18.64							Fee Schedule																				
SINGLE CLIPS (MULTI)	278	RC						Both			21	9.45	9.45	18.9		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	15.54							Fee Schedule																													18.9							Fee Schedule																																															
SINGULAIR  4 MG (MONTELUKAST) GRANULES	250	RC	A9270	CPT				Both			17.12	7.7	0.01	21.44	0.01							Fee Schedule		12.67							Fee Schedule																				18.64							Fee Schedule		15.41							Fee Schedule		21.44							Fee Schedule		17.34							Fee Schedule											21.44							Fee Schedule		17.34							Fee Schedule		
SINGULAIR 10 MG (MONTELUKAST) TABLET	250	RC	A9270	CPT				Both			13.65	6.14	0.01	21.44	0.01							Fee Schedule		10.1							Fee Schedule																				18.64							Fee Schedule		12.29							Fee Schedule		21.44							Fee Schedule		17.34							Fee Schedule											21.44							Fee Schedule		17.34							Fee Schedule		
SINUSES	320	RC	70220	CPT				Both			315	141.75	20.26	318	20.26							Fee Schedule		23.89							Fee Schedule											22.35							Fee Schedule											283.5							Fee Schedule																				318							Per Diem																				
SITERITE SLEEVE 48  FOR PROBE DYNJE5920	270	RC						Both			14	6.3	6.3	12.6	9.1							Fee Schedule		10.36							Fee Schedule																													12.6							Fee Schedule																																															
SITZ BATH #DYND80102	270	RC	E0160	CPT				Both			8	3.6	3.6	34.39	18.26							Fee Schedule		5.92							Fee Schedule		34.39							Fee Schedule																				7.2							Fee Schedule																																															
SITZMARKS (KONSYL PHARMACEUTICALS INC.	270	RC	99070	CPT				Both			345	155.25	10.26	310.5	10.26							Fee Schedule		255.3							Fee Schedule																													310.5							Fee Schedule																																															
SJOGREN'S ANTIBODIES 7832 SERUM	302	RC	86331	CPT				Both			248.85	111.98	10.65	223.97	10.65							Fee Schedule		13.31							Fee Schedule		12.34							Fee Schedule		11.98							Fee Schedule											223.97							Fee Schedule																				11.98							Fee Schedule																				
SKELETAL SURVEY	320	RC	77075	CPT				Both			399	179.55	31.05	359.1	49.37							Fee Schedule		59.29							Fee Schedule											44.4							Fee Schedule		33.39							Fee Schedule		359.1							Fee Schedule		38.4							Fee Schedule		31.05							Fee Schedule		318							Per Diem		38.4							Fee Schedule		31.05							Fee Schedule		
SKIN & NASAL ANTISEPTIC SOL W/SWABS	250	RC	A9270	CPT				Both			50.4	22.68	0.01	45.36	0.01							Fee Schedule		37.3							Fee Schedule																													45.36							Fee Schedule																																															
SKIN AND NASAL ANTISEPTIC SWABS #192401	272	RC						Both			39	17.55	11.14	35.1	25.35							Fee Schedule		28.86							Fee Schedule																				11.98							Fee Schedule		35.1							Fee Schedule		13.78							Fee Schedule		11.14							Fee Schedule											13.78							Fee Schedule		11.14							Fee Schedule		
VIRAL ILLNESS WITHOUT MCC					866	DRG		Inpatient			24496.35	11023.36	11023.36	11023.36							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period	
OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITH CC					868	DRG		Inpatient			16857.86	7586.04	7586.04	7586.04							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period	
SEPTICEMIA OR SEVERE SEPSIS WITH MV >96 HOURS					870	DRG		Inpatient			140513.06	63230.87	63230.87	63230.87							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period	
SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITH MCC					871	DRG		Inpatient			45718.84	20573.48	20573.48	20573.48							0		No services performed during 15 month lookback period. 				2749.83	2749.83	2749.83	1 through 10						10992.94	10992.94	10992.94	1 through 10									0		No services provided during 15 month lookback period				10321.96	3933.38	14584.74	15									0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period				9306.94	9306.94	9306.94	1 through 10									0		No services provided during 15 month lookback period				8339.82	8339.82	8339.82	1 through 10			
SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITHOUT MCC					872	DRG		Inpatient			27769.56	12496.3	12496.3	12496.3							0		No services performed during 15 month lookback period. 				5289.8	5289.8	5289.8	1 through 10									0		No services performed during 15 month lookback period							0		No services provided during 15 month lookback period				5134.36	5134.36	5134.36	1 through 10									0		No services provided during 15 month lookback period				99.41	99.41	99.41	1 through 10						3901.7	3901.7	3901.7	1 through 10									0		No services provided during 15 month lookback							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period	
SKIN PREP WIPES #420400	272	RC	A4245	CPT				Both			1	0.45	0.45	3.19	1.56							Fee Schedule		0.74							Fee Schedule											3.19							Fee Schedule											0.9							Fee Schedule																																															
SKIN SCRIBE MARKING PEN #DYNJSM06	272	RC						Both			2	0.9	0.9	1.8	1.3							Fee Schedule		1.48							Fee Schedule																													1.8							Fee Schedule																																															
SKIN STAPLE RETRACT	272	RC						Both			13.65	6.14	6.14	12.29	8.87							Fee Schedule		10.1							Fee Schedule																													12.29							Fee Schedule																																															
SKIN STAPLER #PMW35 (WAS PMR35)	272	RC						Both			14	6.3	6.3	12.6	9.1							Fee Schedule		10.36							Fee Schedule																													12.6							Fee Schedule																																															
SKIN STAPLER #PRW35	272	RC						Both			53	23.85	23.85	47.7	34.45							Fee Schedule		39.22							Fee Schedule																													47.7							Fee Schedule																																															
SKIN STAPLER EX	272	RC						Both			21	9.45	9.45	18.9	13.65							Fee Schedule		15.54							Fee Schedule																													18.9							Fee Schedule																																															
SKIN STAPLES PXW35 (SENECA)	272	RC						Both			34.65	15.59	15.59	31.19	22.52							Fee Schedule		25.64							Fee Schedule																													31.19							Fee Schedule																																															
SKIN TEMP SENSOR #STS-400	270	RC						Both			6	2.7	2.7	5.4	3.9							Fee Schedule		4.44							Fee Schedule																													5.4							Fee Schedule																																															
ACUTE ADJUSTMENT REACTION AND PSYCHOSOCIAL DYSFUNCTION					880	DRG		Inpatient			11462.9	5158.31	5158.31	5158.31							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period	
SKINSTITCH TOPICAL SKIN ADHESIVE	272	RC	G0168	CPT				Both			52.5	23.63	23.63	47.25	29.43							Fee Schedule		38.85							Fee Schedule																													47.25							Fee Schedule																																															
SKINTEGRITY HYDROGEL TUBE #MSC6204	272	RC						Both			18	8.1	8.1	16.2	11.7							Fee Schedule		13.32							Fee Schedule																													16.2							Fee Schedule																																															
SKULL LESS THAN FOUR VIEWS	320	RC	70250	CPT				Both			315	141.75	17.71	318	19.38							Fee Schedule		22.92							Fee Schedule											17.71							Fee Schedule											283.5							Fee Schedule																				318							Per Diem																				
SKULL MINIMUM FOUR VIEWS	320	RC	70260	CPT				Both			315	141.75	22.88	318	22.88							Fee Schedule		27.14							Fee Schedule											25.31							Fee Schedule											283.5							Fee Schedule																				318							Per Diem																				
SKYRIZI 1200MG/500ML NS IVPB	636	RC	J2327	CPT				Both			76550.52	34447.73	14.6	68895.47		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	14.6							Fee Schedule		15.38							Fee Schedule																				68895.47							Fee Schedule																																															
SKYRIZI 600MG/250ML NS  IVPB	636	RC	J2327	CPT				Both			38275.26	17223.87	14.6	34447.73		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	14.6							Fee Schedule		15.38							Fee Schedule																				34447.73							Fee Schedule																																															
SKYRIZI INTRAVENOUS SOLN 600MG/10ML VIAL	636	RC	J2327	CPT				Both			38275.26	17223.87	14.6	34447.73		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	14.6							Fee Schedule		15.38							Fee Schedule																				34447.73							Fee Schedule																																															
SKYRIZI INTRAVENOUS SOLUTION 600MG/10ML	636	RC	J2327	CPT				Both			38275.26	17223.87	13.89	34447.73		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	14.6							Fee Schedule		15.38							Fee Schedule											14.93							Fee Schedule		34447.73							Fee Schedule		17.17							Fee Schedule		13.89							Fee Schedule											17.17							Fee Schedule		13.89							Fee Schedule		
SLEEP STUDY	740	RC	95810	CPT				Outpatient			2500	1125	13.89	2250	1300							Per Diem		1850							Fee Schedule											156.45							Fee Schedule		14.93							Fee Schedule		2250							Fee Schedule		17.17							Fee Schedule		13.89							Fee Schedule		2122							Per Diem		17.17							Fee Schedule		13.89							Fee Schedule		
SLEEP STUDY  W/ TITRATION	740	RC	95811	CPT				Outpatient			2500	1125	13.89	2250	1300							Per Diem		1850							Fee Schedule											209.96							Fee Schedule		14.93							Fee Schedule		2250							Fee Schedule		17.17							Fee Schedule		13.89							Fee Schedule		2122							Per Diem		17.17							Fee Schedule		13.89							Fee Schedule		
SLO BID 200 MG CAP	250	RC	A9270	CPT				Both			1.58	0.71	0.01	17.17	0.01							Fee Schedule		1.17							Fee Schedule																				14.93							Fee Schedule		1.42							Fee Schedule		17.17							Fee Schedule		13.89							Fee Schedule											17.17							Fee Schedule		13.89							Fee Schedule		
SLO BID 300 MG CAP	250	RC	A9270	CPT				Both			1.58	0.71	0.01	1.42	0.01							Fee Schedule		1.17							Fee Schedule																													1.42							Fee Schedule																																															
SLO BID 50 MG CAP	250	RC	A9270	CPT				Both			1.58	0.71	0.01	1.42	0.01							Fee Schedule		1.17							Fee Schedule																													1.42							Fee Schedule																																															
SLOW K 600 MG TAB	250	RC	A9270	CPT				Both			1.58	0.71	0.01	1.42	0.01							Fee Schedule		1.17							Fee Schedule																													1.42							Fee Schedule																																															
SLOW MAG TABLET	250	RC	A9270	CPT				Both			5.25	2.36	0.01	4.73	0.01							Fee Schedule		3.89							Fee Schedule																													4.73							Fee Schedule																																															
SM AND SM/RNP ANTIBODIES 7448	300	RC	86235	CPT				Both			237.3	106.79	15.94	213.57	15.94							Fee Schedule		19.93							Fee Schedule		18.47							Fee Schedule		17.93							Fee Schedule											213.57							Fee Schedule																				17.93							Fee Schedule																				
SMALL BOWEL	320	RC	74250	CPT				Both			315	141.75	36.83	318	65.38							Fee Schedule		81.37							Fee Schedule											36.83							Fee Schedule											283.5							Fee Schedule																				318							Per Diem																				
SMART SITE ADAPTOR SM500	272	RC						Both			3.15	1.42	1.42	2.84	2.05							Fee Schedule		2.33							Fee Schedule																													2.84							Fee Schedule																																															
SMEARS FILTER PREP	311	RC	88104	CPT				Both			165.9	74.66	16.67	149.31	28.63							Fee Schedule		37.53							Fee Schedule											42.9							Fee Schedule		17.93							Fee Schedule		149.31							Fee Schedule		20.62							Fee Schedule		16.67							Fee Schedule											20.62							Fee Schedule		16.67							Fee Schedule		
SMITH & NEPH ACCU-PASS NEEDLE 7210423	272	RC						Both			420	189	189	378	273							Fee Schedule		310.8							Fee Schedule																													378							Fee Schedule																																															
SMITH & NEPH ANKLE DISTR. STRAP #014407	272	RC						Both			166	74.7	74.7	149.4	107.9							Fee Schedule		122.84							Fee Schedule																													149.4							Fee Schedule																																															
SMITH & NEPH AWL TAPPED 72202621	272	RC						Both			141.75	63.79	63.79	127.58	92.14							Fee Schedule		104.9							Fee Schedule																													127.58							Fee Schedule																																															
SMITH & NEPH DRILL BIT/GUIDEPEN 72201201	272	RC						Both			151	67.95	67.95	135.9	98.15							Fee Schedule		111.74							Fee Schedule																													135.9							Fee Schedule																																															
SMITH & NEPH DYONICS PATIENT TUBE 721100	272	RC						Both			115	51.75	51.75	103.5	74.75							Fee Schedule		85.1							Fee Schedule																													103.5							Fee Schedule																																															
SMITH & NEPH DYONICS TUBE SET 7211007	272	RC						Both			191	85.95	85.95	171.9	124.15							Fee Schedule		141.34							Fee Schedule																													171.9							Fee Schedule																																															
SMITH & NEPH ENDOBUTTON 013186	278	RC	C1713	CPT				Both			630	283.5	283.5	567		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	466.2							Fee Schedule																													567							Fee Schedule																																															
SMITH & NEPH FEM. COMP. #71420008	278	RC	C1776	CPT				Both			7639.8	3437.91	3437.91	6875.82		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	5653.45							Fee Schedule																													6875.82							Fee Schedule																																															
SMITH & NEPH GOFLO TUBE SET #T0449-01	272	RC						Both			121	54.45	54.45	108.9	78.65							Fee Schedule		89.54							Fee Schedule																													108.9							Fee Schedule																																															
SMITH & NEPH HEALICOIL  72203378	278	RC	C1713	CPT				Both			1044.75	470.14	470.14	940.28		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	773.12							Fee Schedule																													940.28							Fee Schedule																																															
SMITH & NEPH HEALICOIL  72203704	278	RC	C1713	CPT				Both			1190.7	535.82	535.82	1071.63		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	881.12							Fee Schedule																													1071.63							Fee Schedule																																															
SMITH & NEPH HEALICOIL  72203983	278	RC	C1713	CPT				Both			960	432	432	864		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	710.4							Fee Schedule																													864							Fee Schedule																																															
SMITH & NEPH HEALICOIL  72203984	278	RC	C1713	CPT				Both			960	432	432	864		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	710.4							Fee Schedule																													864							Fee Schedule																																															
SMITH & NEPH SUTURE ANCHOR 25-2800	278	RC	C1713	CPT				Both			2139	962.55	962.55	1925.1		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1582.86							Fee Schedule																													1925.1							Fee Schedule																																															
SMITH & NEPH SUTURE ANCHOR 25-2810	278	RC	C1713	CPT				Both			1746	785.7	785.7	1571.4		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1292.04							Fee Schedule																													1571.4							Fee Schedule																																															
SMITH & NEPH SUTURE ANCHOR 72202595	278	RC	C1713	CPT				Both			705	317.25	317.25	634.5		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	521.7							Fee Schedule																													634.5							Fee Schedule																																															
SMITH & NEPH SUTURE ANCHOR 72202599	278	RC	C1713	CPT				Both			705	317.25	317.25	634.5		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	521.7							Fee Schedule																													634.5							Fee Schedule																																															
SMITH & NEPH SUTURE ANCHOR 72202625	278	RC	C1713	CPT				Both			705	317.25	317.25	634.5		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	521.7							Fee Schedule																													634.5							Fee Schedule																																															
SMITH & NEPH SUTURE ANCHOR 72202901	278	RC	C1713	CPT				Both			1114.05	501.32	501.32	1002.65		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	824.4							Fee Schedule																													1002.65							Fee Schedule																																															
SMITH & NEPH SUTURE ANCHOR 72202902	278	RC	C1713	CPT				Both			1110	499.5	499.5	999		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	821.4							Fee Schedule																													999							Fee Schedule																																															
SMITH & NEPH SUTURE ANCHOR 72205137	278	RC	C1713	CPT				Both			1260	567	567	1134		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	932.4							Fee Schedule																													1134							Fee Schedule																																															
SMITH & NEPH SUTURE ANCHOR 72205381	278	RC	C1713	CPT				Both			1350	607.5	607.5	1215		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	999							Fee Schedule																													1215							Fee Schedule																																															
SMITH & NEPH SUTURE ANCHOR 72205382	278	RC	C1713	CPT				Both			1245	560.25	560.25	1120.5		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	921.3							Fee Schedule																													1120.5							Fee Schedule																																															
SMITH & NEPH ULTRATAPE 72203896	272	RC						Both			195	87.75	87.75	175.5	126.75							Fee Schedule		144.3							Fee Schedule																													175.5							Fee Schedule																																															
SMITH & NEPH VULC ABRADOR 72200683	272	RC						Both			1650.6	742.77	742.77	1485.54	1072.89							Fee Schedule		1221.44							Fee Schedule																													1485.54							Fee Schedule																																															
SMITH & NEPH. ACETAB. PINS # 71366301	278	RC	C1776	CPT				Both			241.5	108.68	108.68	217.35		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	178.71							Fee Schedule																													217.35							Fee Schedule																																															
SMITH & NEPH. FEM. COMP. #71420150	278	RC	C1776	CPT				Both			15054.9	6774.71	6774.71	13549.41		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	11140.63							Fee Schedule																													13549.41							Fee Schedule																																															
SMITH & NEPH. PELVIS PINS # 71366302	278	RC	C1776	CPT				Both			248.85	111.98	111.98	223.97		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	184.15							Fee Schedule																													223.97							Fee Schedule																																															
SMITH & NEPHEW ABRADER BLADE 2.9MM 3530	272	RC						Both			107.1	48.2	48.2	96.39	69.62							Fee Schedule		79.25							Fee Schedule																													96.39							Fee Schedule																																															
SMITH & NEPHEW ABRULAT PROBE 72200-683	272	RC						Both			1685.25	758.36	758.36	1516.73	1095.41							Fee Schedule		1247.09							Fee Schedule																													1516.73							Fee Schedule																																															
SMITH & NEPHEW BIORET SCREW #7209012	278	RC	C1713	CPT				Both			834	375.3	375.3	750.6		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	617.16							Fee Schedule																													750.6							Fee Schedule																																															
SMITH & NEPHEW BIOSURE SCREW #72201775	278	RC	C1713	CPT				Both			891	400.95	400.95	801.9		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	659.34							Fee Schedule																													801.9							Fee Schedule																																															
SMITH & NEPHEW BIOSURE SCREW #72201776	278	RC	C1713	CPT				Both			891	400.95	400.95	801.9		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	659.34							Fee Schedule																													801.9							Fee Schedule																																															
SMITH & NEPHEW BIOSURE SCREW #72201780	278	RC	C1713	CPT				Both			891	400.95	400.95	801.9		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	659.34							Fee Schedule																													801.9							Fee Schedule																																															
SMITH & NEPHEW BIOSURE SCREW #72201781	278	RC	C1713	CPT				Both			891	400.95	400.95	801.9		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	659.34							Fee Schedule																													801.9							Fee Schedule																																															
SMITH & NEPHEW BIOSURE SCREW #72201785	278	RC	C1713	CPT				Both			891	400.95	400.95	801.9		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	659.34							Fee Schedule																													801.9							Fee Schedule																																															
SMITH & NEPHEW CANNULA SYSTEM 72200424	272	RC						Both			75.6	34.02	34.02	68.04	49.14							Fee Schedule		55.94							Fee Schedule																													68.04							Fee Schedule																																															
SMITH & NEPHEW CANNULA SYSTEM 72200425	272	RC						Both			101	45.45	45.45	90.9	65.65							Fee Schedule		74.74							Fee Schedule																													90.9							Fee Schedule																																															
SMITH & NEPHEW CANNULA SYSTEM 72200427	272	RC						Both			88	39.6	39.6	79.2	57.2							Fee Schedule		65.12							Fee Schedule																													79.2							Fee Schedule																																															
SMITH & NEPHEW DRILL BIT 7207315	270	RC						Both			460	207	207	414	299							Fee Schedule		340.4							Fee Schedule																													414							Fee Schedule																																															
SMITH & NEPHEW FEM. COMP. #71420156	278	RC	C1776	CPT				Both			13482	6066.9	6066.9	12133.8		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	9976.68							Fee Schedule																													12133.8							Fee Schedule																																															
SMITH & NEPHEW FIXATION DEVICE 72200134	278	RC	C1713	CPT				Both			555.45	249.95	249.95	499.91		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	411.03							Fee Schedule																													499.91							Fee Schedule																																															
SMITH & NEPHEW KNOT PUSHER 72202674	272	RC						Both			492	221.4	221.4	442.8	319.8							Fee Schedule		364.08							Fee Schedule																													442.8							Fee Schedule																																															
SMITH & NEPHEW MINI SUTURE PASS 72290128	272	RC	A4649	CPT				Both			642.6	289.17	289.17	578.34	417.69							Fee Schedule		475.52							Fee Schedule																													578.34							Fee Schedule																																															
SMITH & NEPHEW PASSING PIN #72201594	278	RC	C1713	CPT				Both			405.3	182.39	182.39	364.77		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	299.92							Fee Schedule																													364.77							Fee Schedule																																															
SMITH & NEPHEW RAP-PAC B #72202796	278	RC	C1769	CPT				Both			905	407.25	407.25	814.5		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	669.7							Fee Schedule																													814.5							Fee Schedule																																															
SMITH & NEPHEW RAP-PAC B #72202797	278	RC	C1769	CPT				Both			905	407.25	407.25	814.5		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	669.7							Fee Schedule																													814.5							Fee Schedule																																															
SMITH & NEPHEW SPHERICAL HEAD CANCEL.6.5	278	RC						Both			242.55	109.15	109.15	218.3		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	179.49							Fee Schedule																													218.3							Fee Schedule																																															
SMITH & NEPHEW STOPCOCK VALVE 72200658	272	RC						Both			17.85	8.03	8.03	16.07	11.6							Fee Schedule		13.21							Fee Schedule																													16.07							Fee Schedule																																															
SMITH & NEPHEW SUPER MULTBACK ASC4830-01	270	RC						Both			327.6	147.42	147.42	294.84	212.94							Fee Schedule		242.42							Fee Schedule																													294.84							Fee Schedule																																															
SMITH & NEPHEW SYNERGY FEM COMP 71306113	278	RC	C1776	CPT				Both			9692.55	4361.65	4361.65	8723.3		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	7172.49							Fee Schedule																													8723.3							Fee Schedule																																															
SMITH NEPHEW LEFT  SUTURE PASS 72290129	272	RC	A4649	CPT				Both			787.5	354.38	354.38	708.75	511.88							Fee Schedule		582.75							Fee Schedule																													708.75							Fee Schedule																																															
SMITH NEPHEW MENSIC ULTRABRAID 71935069	278	RC	L8699	CPT				Both			2114.7	951.62	951.62	1903.23		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1564.88							Fee Schedule																													1903.23							Fee Schedule																																															
SMITH NEPHEW MENSIC ULTRABRAID 71935070	278	RC	L8699	CPT				Both			2554.34	1149.45	1149.45	2298.91		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1890.21							Fee Schedule																													2298.91							Fee Schedule																																															
SMITH NEPHEW NOVOCUT SUT. CUTR. CTX-C001	272	RC	A4649	CPT				Both			551.25	248.06	248.06	496.13	358.31							Fee Schedule		407.93							Fee Schedule																													496.13							Fee Schedule																																															
SMITH NEPHEW NOVOSTITCH  0   CTX-A004	272	RC	A4649	CPT				Both			1543.5	694.58	694.58	1389.15	1003.28							Fee Schedule		1142.19							Fee Schedule																													1389.15							Fee Schedule																																															
SMITH NEPHEW NOVOSTITCH  2-0   CTX-A003	272	RC	A4649	CPT				Both			1543.5	694.58	694.58	1389.15	1003.28							Fee Schedule		1142.19							Fee Schedule																													1389.15							Fee Schedule																																															
SMITH NEPHEW NOVOSTITCH CARTDG. CTX-R001	278	RC	A4649	CPT				Both			1338.75	602.44	602.44	1204.88		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	990.68							Fee Schedule																													1204.88							Fee Schedule																																															
SMITH NEPHEW NOVOSTITCH CARTDG. CTX-R002	278	RC	A4649	CPT				Both			1338.75	602.44	602.44	1204.88		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	990.68							Fee Schedule																													1204.88							Fee Schedule																																															
SMITH NEPHEW RIGHT  SUTURE PASS 72290130	272	RC	A4649	CPT				Both			787.5	354.38	354.38	708.75	511.88							Fee Schedule		582.75							Fee Schedule																													708.75							Fee Schedule																																															
SMITH&NEPH  SCREW 72204395	278	RC	C1776	CPT				Both			1886.85	849.08	849.08	1698.17		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1396.27							Fee Schedule																													1698.17							Fee Schedule																																															
SMITH&NEPH 12 HIGH STEM #71306112	278	RC	C1776	CPT				Both			12358.5	5561.33	5561.33	11122.65		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	9145.29							Fee Schedule																													11122.65							Fee Schedule																																															
SMITH&NEPH 3 HOLE POROUS 71336462	278	RC	C1776	CPT				Both			7483.35	3367.51	3367.51	6735.02		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	5537.68							Fee Schedule																													6735.02							Fee Schedule																																															
SMITH&NEPH 52MM ACET SHELL#71336452	278	RC	C1776	CPT				Both			6252.75	2813.74	2813.74	5627.48		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	4627.04							Fee Schedule																													5627.48							Fee Schedule																																															
SMITH&NEPH ACETAB. LINER #71333324	278	RC	C1776	CPT				Both			3370.5	1516.73	1516.73	3033.45		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	2494.17							Fee Schedule																													3033.45							Fee Schedule																																															
SMITH&NEPH ACETABULAR SHELL 3 HOLE	278	RC	C1776	CPT				Both			3410.4	1534.68	1534.68	3069.36		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	2523.7							Fee Schedule																													3069.36							Fee Schedule																																															
SMITH&NEPH ARTIC INSERT #71420816	278	RC	C1776	CPT				Both			2835	1275.75	1275.75	2551.5		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	2097.9							Fee Schedule																													2551.5							Fee Schedule																																															
SMITH&NEPH BONE TUNNEL PLUG 014477	278	RC						Both			134	60.3	60.3	120.6		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	99.16							Fee Schedule																													120.6							Fee Schedule																																															
SMITH&NEPH CANC. SCREW 6.5 #71332520	278	RC	C1713	CPT				Both			337.05	151.67	151.67	303.35		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	249.42							Fee Schedule																													303.35							Fee Schedule																																															
SMITH&NEPH CEM.STEM FEM.COMP. #71316011	278	RC	C1776	CPT				Both			6342	2853.9	2853.9	5707.8		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	4693.08							Fee Schedule																													5707.8							Fee Schedule																																															
SMITH&NEPH DIST. POST #71313211	278	RC	C1776	CPT				Both			3033.45	1365.05	1365.05	2730.11		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	2244.75							Fee Schedule																													2730.11							Fee Schedule																																															
SMITH&NEPH DIST.POST CENTRAL.#71313209	278	RC	C1776	CPT				Both			242.55	109.15	109.15	218.3		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	179.49							Fee Schedule																													218.3							Fee Schedule																																															
SMITH&NEPH ECHILON CEM.SREM #71310116	278	RC	C1776	CPT				Both			7529.55	3388.3	3388.3	6776.6		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	5571.87							Fee Schedule																													6776.6							Fee Schedule																																															
SMITH&NEPH FAST FIX 360 CURVE 72202468	278	RC	C1713	CPT				Both			1275	573.75	573.75	1147.5		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	943.5							Fee Schedule																													1147.5							Fee Schedule																																															
SMITH&NEPH FAST FIX 360 REV. CUR72202469	278	RC	C1713	CPT				Both			1275	573.75	573.75	1147.5		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	943.5							Fee Schedule																													1147.5							Fee Schedule																																															
SMITH&NEPH FAST FIX 360 STRAI. 72202467	278	RC	C1713	CPT				Both			1275	573.75	573.75	1147.5		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	943.5							Fee Schedule																													1147.5							Fee Schedule																																															
SMITH&NEPH FEM. COMP. #71420120	278	RC	C1776	CPT				Both			7711.2	3470.04	3470.04	6940.08		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	5706.29							Fee Schedule																													6940.08							Fee Schedule																																															
SMITH&NEPH FEM.COMP. #71316214	278	RC	C1776	CPT				Both			8538.6	3842.37	3842.37	7684.74		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	6318.56							Fee Schedule																													7684.74							Fee Schedule																																															
SMITH&NEPH FEMORAL COMPONENT #71306114	278	RC	C1776	CPT				Both			12730.2	5728.59	5728.59	11457.18		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	9420.35							Fee Schedule																													11457.18							Fee Schedule																																															
SMITH&NEPH FEMORAL COMPONENT #71306614	278	RC	C1776	CPT				Both			13151.25	5918.06	5918.06	11836.13		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	9731.93							Fee Schedule																													11836.13							Fee Schedule																																															
SMITH&NEPH FEMORAL COMPONENT #71420102	278	RC	C1776	CPT				Both			7415.1	3336.8	3336.8	6673.59		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	5487.17							Fee Schedule																													6673.59							Fee Schedule																																															
SMITH&NEPH LINER 71333337	278	RC	C1776	CPT				Both			6673.8	3003.21	3003.21	6006.42		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	4938.61							Fee Schedule																													6006.42							Fee Schedule																																															
SMITH&NEPH MED.UNIPOLAR #71701035	278	RC	C1776	CPT				Both			10448.55	4701.85	4701.85	9403.7		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	7731.93							Fee Schedule																													9403.7							Fee Schedule																																															
SMITH&NEPH MENSIC ULTRATAPE 71935068	278	RC	L8699	CPT				Both			2554.34	1149.45	1149.45	2298.91		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1890.21							Fee Schedule																													2298.91							Fee Schedule																																															
SMITH&NEPH PASSING PIN 014508	278	RC						Both			281.4	126.63	126.63	253.26		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	208.24							Fee Schedule																													253.26							Fee Schedule																																															
SMITH&NEPH PIN PASSING DRILL TIP 7208678	272	RC						Both			417	187.65	187.65	375.3	271.05							Fee Schedule		308.58							Fee Schedule																													375.3							Fee Schedule																																															
SMITH&NEPH PLATFORM 74435947	278	RC	C1776	CPT				Both			18572.4	8357.58	8357.58	16715.16		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	13743.58							Fee Schedule																													16715.16							Fee Schedule																																															
SMITH&NEPH TOTAL KNEE CAPITATED RATE	278	RC	C1776	CPT				Both			17010	7654.5	7654.5	15309		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	12587.4							Fee Schedule																													15309							Fee Schedule																																															
SMITH&NEPH TROCAR PIN 1/8  X 5	278	RC						Both			85.05	38.27	38.27	76.55		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	62.94							Fee Schedule																													76.55							Fee Schedule																																															
SMITH&NEPH TROCAR PIN I/8 X3	278	RC						Both			85.05	38.27	38.27	76.55		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	62.94							Fee Schedule																													76.55							Fee Schedule																																															
SMITH&NEPH UNIPOLAR 12/14 TAPERSLEEV +4	278	RC	C1776	CPT				Both			270.9	121.91	121.91	243.81		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	200.47							Fee Schedule																													243.81							Fee Schedule																																															
SMITH&NEPH UNIPOLAR 13/14 TAPER SLEEVE+0	278	RC	C1776	CPT				Both			270.9	121.91	121.91	243.81		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	200.47							Fee Schedule																													243.81							Fee Schedule																																															
SMITH&NEPH. FEM. COMP. #71316517	278	RC	C1776	CPT				Both			5617.5	2527.88	2527.88	5055.75		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	4156.95							Fee Schedule																													5055.75							Fee Schedule																																															
SMITH&NEPH. FRM. COMP. #71420058	278	RC	C1776	CPT				Both			10111.5	4550.18	4550.18	9100.35		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	7482.51							Fee Schedule																													9100.35							Fee Schedule																																															
SMITH&NEPH.TIBIAL PLATE #71420186	278	RC	C1776	CPT				Both			4943.4	2224.53	2224.53	4449.06		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	3658.12							Fee Schedule																													4449.06							Fee Schedule																																															
SMITH&NEPH.UNIPOLAR HEAD STEM#126652	278	RC	C1776	CPT				Both			1235.85	556.13	556.13	1112.27		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	914.53							Fee Schedule																													1112.27							Fee Schedule																																															
SMOKE EVAC  #60-6810-001  ( CONMED )	271	RC						Both			36.75	16.54	16.54	33.08	23.89							Fee Schedule		27.2							Fee Schedule																													33.08							Fee Schedule																																															
SMOKE EVAC HIGHFLOW 0620050250  ENDO	272	RC						Both			143	64.35	64.35	128.7	92.95							Fee Schedule		105.82							Fee Schedule																													128.7							Fee Schedule																																															
SMOKE EVAC TUB. 905017	272	RC						Both			21	9.45	9.45	18.9	13.65							Fee Schedule		15.54							Fee Schedule																													18.9							Fee Schedule																																															
SMOKE EVAC TUBING #1207810 (COASTALLIFES	271	RC						Both			85.05	38.27	38.27	76.55	55.28							Fee Schedule		62.94							Fee Schedule																													76.55							Fee Schedule																																															
SMOKE EVAC TUBING 901015	271	RC						Both			77	34.65	34.65	69.3	50.05							Fee Schedule		56.98							Fee Schedule																													69.3							Fee Schedule																																															
SMOKE EVAC TUBING ADAPTER  905015-000	271	RC						Both			22	9.9	9.9	19.8	14.3							Fee Schedule		16.28							Fee Schedule																													19.8							Fee Schedule																																															
SMOOTH MUSCLE ANTIBODIES 263 SERUM	302	RC	86255	CPT				Both			68.25	30.71	10.71	61.43	10.71							Fee Schedule		13.39							Fee Schedule		12.41							Fee Schedule		12.05							Fee Schedule											61.43							Fee Schedule																				12.05							Fee Schedule																				
SNYDER HEMOVAC SET	272	RC						Both			95.55	43	43	86	62.11							Fee Schedule		70.71							Fee Schedule																													86							Fee Schedule																																															
SOD BICARB 8.4% 1 MEQ/ML SDV 50 ML	250	RC						Both			7.25	3.26	3.26	6.53	4.71							Fee Schedule		5.37							Fee Schedule																													6.53							Fee Schedule																																															
SOD BICARBONATE  2.5 MEQ/5ML VIAL	250	RC						Both			11.55	5.2	5.2	13.86	7.51							Fee Schedule		8.55							Fee Schedule																				12.05							Fee Schedule		10.4							Fee Schedule		13.86							Fee Schedule		11.21							Fee Schedule											13.86							Fee Schedule		11.21							Fee Schedule		
SOD POLY SULF 15 GM/ 60 ML ORAL SUSP UD	250	RC	A9270	CPT				Both			35.7	16.07	0.01	32.13	0.01							Fee Schedule		26.42							Fee Schedule																													32.13							Fee Schedule																																															
SOD POLY SULF 15 GM/60ML ORAL SUSP-473ML	250	RC	A9270	CPT				Both			348.6	156.87	0.01	313.74	0.01							Fee Schedule		257.96							Fee Schedule																													313.74							Fee Schedule																																															
SOD POLY SULF 15GM POWDER	250	RC	A9270	CPT				Both			49.35	22.21	0.01	44.42	0.01							Fee Schedule		36.52							Fee Schedule																													44.42							Fee Schedule																																															
SOD SUL 30% OPTH SOL	250	RC	A9270	CPT				Both			14.52	6.53	0.01	13.07	0.01							Fee Schedule		10.74							Fee Schedule																													13.07							Fee Schedule																																															
SODIUM	301	RC	84295	CPT				Both			54.6	24.57	4.28	49.14	4.28							Fee Schedule		5.35							Fee Schedule		4.95							Fee Schedule		4.81							Fee Schedule											49.14							Fee Schedule																				4.81							Fee Schedule																				
SODIUM  BICARB 44.6 MEQ  7.5% SYRINGE	250	RC	A9270	CPT				Both			6.93	3.12	0.01	6.24	0.01							Fee Schedule		5.13							Fee Schedule																													6.24							Fee Schedule																																															
SODIUM  BICARB 50 MEQ/50ML (8.4%) PFS	250	RC	A9270	CPT				Both			39.9	17.96	0.01	35.91	0.01							Fee Schedule		29.53							Fee Schedule																													35.91							Fee Schedule																																															
SODIUM  BICARB 50 MEQ/50ML (8.4%)VIAL	250	RC	A9270	CPT				Both			75.6	34.02	0.01	68.04	0.01							Fee Schedule		55.94							Fee Schedule																				4.81							Fee Schedule		68.04							Fee Schedule		5.53							Fee Schedule		4.47							Fee Schedule											5.53							Fee Schedule		4.47							Fee Schedule		
SODIUM  URINE 24 HR 11317 REF LAB	301	RC	84300	CPT				Both			56.7	25.52	4.32	51.03	4.32							Fee Schedule		5.4							Fee Schedule		5.21							Fee Schedule		5.06							Fee Schedule											51.03							Fee Schedule																				5.06							Fee Schedule																				
SODIUM ACETATE 40 MEQ/20ML-20ML	250	RC	A9270	CPT				Both			14.7	6.62	0.01	13.23	0.01							Fee Schedule		10.88							Fee Schedule																													13.23							Fee Schedule																																															
SODIUM BICARB 0.5MEQ/ML (4.2%) 10ML VIAL	250	RC	A9270	CPT				Both			26.64	11.99	0.01	23.98	0.01							Fee Schedule		19.71							Fee Schedule																													23.98							Fee Schedule																																															
SODIUM BICARB 100mEq/STERILE WATER 1000	250	RC						Both			17.85	8.03	4.71	16.07	11.6							Fee Schedule		13.21							Fee Schedule																				5.06							Fee Schedule		16.07							Fee Schedule		5.82							Fee Schedule		4.71							Fee Schedule											5.82							Fee Schedule		4.71							Fee Schedule		
SODIUM BICARB 150mEq/STERILE WATER 1000	250	RC						Both			17.85	8.03	8.03	16.07	11.6							Fee Schedule		13.21							Fee Schedule																													16.07							Fee Schedule																																															
SODIUM BICARB 1MEQ/ML (8.4%)PED PFS	250	RC	A9270	CPT				Both			11.55	5.2	0.01	10.4	0.01							Fee Schedule		8.55							Fee Schedule																													10.4							Fee Schedule																																															
SODIUM BICARB 1MEQ/ML(8.4%)PED 10ML VIAL	250	RC	A9270	CPT				Both			33.12	14.9	0.01	29.81	0.01							Fee Schedule		24.51							Fee Schedule																													29.81							Fee Schedule																																															
SODIUM BICARB DRIP 1000ML (ER STANDARD)	250	RC	A9270	CPT				Both			91.35	41.11	0.01	82.22	0.01							Fee Schedule		67.6							Fee Schedule																													82.22							Fee Schedule																																															
SODIUM BICARBONATE 650MG (10GR) TABLET	250	RC	A9270	CPT				Both			5.25	2.36	0.01	4.73	0.01							Fee Schedule		3.89							Fee Schedule																													4.73							Fee Schedule																																															
SODIUM CHL 1 GM TAB	250	RC	A9270	CPT				Both			1.58	0.71	0.01	1.42	0.01							Fee Schedule		1.17							Fee Schedule																													1.42							Fee Schedule																																															
SODIUM CHLORIDE  50 MEQ/20ML-40ML VIAL	250	RC	J7131	CPT				Both			21	9.45	0.03	18.9	0.03							Fee Schedule		15.54							Fee Schedule																													18.9							Fee Schedule																																															
SODIUM CHLORIDE 1GM TABLET	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
SODIUM CHLORIDE 5% OPTH OINT- 3.5GM	250	RC	A9270	CPT				Both			53.55	24.1	0.01	48.2	0.01							Fee Schedule		39.63							Fee Schedule																													48.2							Fee Schedule																																															
SODIUM CHLORIDE 5% OPTHL SOLN	250	RC	A9270	CPT				Both			54.34	24.45	0.01	48.91	0.01							Fee Schedule		40.21							Fee Schedule																													48.91							Fee Schedule																																															
SODIUM CITRATE/CITRIC ACID SOLN-15ML SF	250	RC	A9270	CPT				Both			11.55	5.2	0.01	10.4	0.01							Fee Schedule		8.55							Fee Schedule																													10.4							Fee Schedule																																															
SODIUM PHOS 15MMOL/NS 250ML IVPB	250	RC	A9270	CPT				Both			72.36	32.56	0.01	65.12	0.01							Fee Schedule		53.55							Fee Schedule																													65.12							Fee Schedule																																															
SODIUM PHOS 21MMOL/NS 250ML IVPB	250	RC	A9270	CPT				Both			72.36	32.56	0.01	65.12	0.01							Fee Schedule		53.55							Fee Schedule																													65.12							Fee Schedule																																															
SODIUM PHOS 30MMOL/NS 250ML IVPB	250	RC	A9270	CPT				Both			72.36	32.56	0.01	65.12	0.01							Fee Schedule		53.55							Fee Schedule																													65.12							Fee Schedule																																															
SODIUM PHOSPHATES 150MMOL/50ML VIAL	250	RC	A9270	CPT				Both			433.8	195.21	0.01	390.42	0.01							Fee Schedule		321.01							Fee Schedule																													390.42							Fee Schedule																																															
SODIUM PHOSPHATES 15MMOL/5ML VIAL	250	RC	A9270	CPT				Both			61.32	27.59	0.01	55.19	0.01							Fee Schedule		45.38							Fee Schedule																													55.19							Fee Schedule																																															
SODIUM URINE	301	RC	84300	CPT				Both			30.45	13.7	4.32	27.41	4.32							Fee Schedule		5.4							Fee Schedule		5.21							Fee Schedule		5.06							Fee Schedule											27.41							Fee Schedule																				5.06							Fee Schedule																				
SOFBAN 6	272	RC						Both			9.45	4.25	4.25	8.51	6.14							Fee Schedule		6.99							Fee Schedule																													8.51							Fee Schedule																																															
SOFSORB DRESSING L 46-115	272	RC	A6253	CPT				Both			22	9.9	5.7	19.8	5.7							Fee Schedule		16.28							Fee Schedule		9.3							Fee Schedule		7.13							Fee Schedule											19.8							Fee Schedule																																															
SOFSORB DRESSING M 46-113	272	RC	A6253	CPT				Both			17.85	8.03	4.71	16.07	5.7							Fee Schedule		13.21							Fee Schedule		9.3							Fee Schedule		7.13							Fee Schedule		5.06							Fee Schedule		16.07							Fee Schedule		5.82							Fee Schedule		4.71							Fee Schedule											5.82							Fee Schedule		4.71							Fee Schedule		
SOFSORB DRESSING ML 46-114	272	RC	A6253	CPT				Both			26.25	11.81	5.7	23.63	5.7							Fee Schedule		19.43							Fee Schedule		9.3							Fee Schedule		7.13							Fee Schedule											23.63							Fee Schedule																																															
SOFSORB DRESSING S 46-112	272	RC	A6253	CPT				Both			17.85	8.03	5.7	16.07	5.7							Fee Schedule		13.21							Fee Schedule		9.3							Fee Schedule		7.13							Fee Schedule		9.03							Fee Schedule		16.07							Fee Schedule		10.38							Fee Schedule		8.4							Fee Schedule											10.38							Fee Schedule		8.4							Fee Schedule		
SOFSORB DRESSING XL 46-116	272	RC	A6253	CPT				Both			36.75	16.54	5.7	33.08	5.7							Fee Schedule		27.2							Fee Schedule		9.3							Fee Schedule		7.13							Fee Schedule		9.03							Fee Schedule		33.08							Fee Schedule		10.38							Fee Schedule		8.4							Fee Schedule											10.38							Fee Schedule		8.4							Fee Schedule		
SOFSORB DRESSING XS 46-111	272	RC	A6253	CPT				Both			17.85	8.03	5.7	16.07	5.7							Fee Schedule		13.21							Fee Schedule		9.3							Fee Schedule		7.13							Fee Schedule		9.03							Fee Schedule		16.07							Fee Schedule		10.38							Fee Schedule		8.4							Fee Schedule											10.38							Fee Schedule		8.4							Fee Schedule		
SOFT CAP #302142  (TRI-ANIM)	270	RC						Both			3.15	1.42	1.42	10.38	2.05							Fee Schedule		2.33							Fee Schedule																				9.03							Fee Schedule		2.84							Fee Schedule		10.38							Fee Schedule		8.4							Fee Schedule											10.38							Fee Schedule		8.4							Fee Schedule		
SOFT TISSUE COMPONENT TRAY #2 # 4382SA	272	RC						Both			73.5	33.08	8.4	66.15	47.78							Fee Schedule		54.39							Fee Schedule																				9.03							Fee Schedule		66.15							Fee Schedule		10.38							Fee Schedule		8.4							Fee Schedule											10.38							Fee Schedule		8.4							Fee Schedule		
SOFT TISSUE NECK	320	RC	70360	CPT				Both			315	141.75	8.4	318	16.18							Fee Schedule		19.67							Fee Schedule											11.95							Fee Schedule		9.03							Fee Schedule		283.5							Fee Schedule		10.38							Fee Schedule		8.4							Fee Schedule		318							Per Diem		10.38							Fee Schedule		8.4							Fee Schedule		
ORGANIC DISTURBANCES AND INTELLECTUAL DISABILITY					884	DRG		Inpatient			28040.73	12618.33	12618.33	12618.33							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period							0		No services provided during 15 month lookback period				8838.34	8838.34	8838.34	1 through 10									0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period	
PSYCHOSES					885	DRG		Inpatient			9063.5	4078.58	4078.58	4078.58							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period	
SOFT TISSUE TRAY COMPONENT #1 SK1016A	272	RC						Both			59.33	26.7	26.7	53.4	38.56							Fee Schedule		43.9							Fee Schedule																													53.4							Fee Schedule																																															
SOFT TLSO	274	RC	L0486	CPT				Both			6573	2957.85	2231.6	5915.7		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	4864.02							Fee Schedule		2231.6							Fee Schedule																				5915.7							Fee Schedule																																															
SOLO PASS STENT 3406	278	RC	C1877	CPT				Both			388.5	174.83	174.83	349.65		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	287.49							Fee Schedule																													349.65							Fee Schedule																																															
SOLTIVE TFL FIBER 150 MICRON TFL-FBX150S	272	RC						Both			1352	608.4	608.4	1216.8	878.8							Fee Schedule		1000.48							Fee Schedule																													1216.8							Fee Schedule																																															
SOLTIVE TFL FIBER 200 MICRON TFLFBX200BS	272	RC						Both			1782	801.9	801.9	2491.59	1158.3							Fee Schedule		1318.68							Fee Schedule																				2166.6							Fee Schedule		1603.8							Fee Schedule		2491.59							Fee Schedule		2014.94							Fee Schedule											2491.59							Fee Schedule		2014.94							Fee Schedule		
SOLTIVE TFL FIBER 940 MICRON TFL-FBX940S	272	RC						Both			2382	1071.9	1071.9	2143.8	1548.3							Fee Schedule		1762.68							Fee Schedule																													2143.8							Fee Schedule																																															
SOLUBLE LIVER AG/AUTO AB 38928 1ML S  RE	301	RC	83520	CPT				Both			183.75	82.69	12.43	165.38	12.43							Fee Schedule		17.27							Fee Schedule		17.79							Fee Schedule		17.27							Fee Schedule											165.38							Fee Schedule																				17.27							Fee Schedule																				
SOLUBLE TRANSF RECEPTOR ASSAY 91031	301	RC	84238	CPT				Both			354.9	159.71	32.5	319.41	32.5							Fee Schedule		40.63							Fee Schedule		37.67							Fee Schedule		36.57							Fee Schedule											319.41							Fee Schedule																				36.57							Fee Schedule																				
SOLUCORTEF 100 MG/2ML VIAL	636	RC	J1720	CPT				Both			11.55	5.2	5.2	23.75		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	8.55							Fee Schedule		23.75							Fee Schedule		6.44							Fee Schedule											10.4							Fee Schedule																																															
SOLUCORTEF 250 MG/2ML VIAL	636	RC	J1720	CPT				Both			11.55	5.2	5.2	23.75		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	8.55							Fee Schedule		23.75							Fee Schedule		6.44							Fee Schedule		17.27							Fee Schedule		10.4							Fee Schedule		19.86							Fee Schedule		16.06							Fee Schedule											19.86							Fee Schedule		16.06							Fee Schedule		
SOLUMEDROL  40 MG/ML VIAL	636	RC	J2919	CPT				Both			23.1	10.4	0.23	42.06		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	17.09							Fee Schedule		0.23							Fee Schedule											36.57							Fee Schedule		20.79							Fee Schedule		42.06							Fee Schedule		34.01							Fee Schedule											42.06							Fee Schedule		34.01							Fee Schedule		
SOLUMEDROL 1 GM/NS 250ML IVPB	636	RC	J2919	CPT				Both			178.5	80.33	0.23	160.65		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	132.09							Fee Schedule		0.23							Fee Schedule											23.06							Fee Schedule		160.65							Fee Schedule		26.51							Fee Schedule		21.44							Fee Schedule											26.51							Fee Schedule		21.44							Fee Schedule		
SOLUMEDROL 125 MG/2ML VIAL	636	RC	J2919	CPT				Both			36.75	16.54	0.23	33.08		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	27.2							Fee Schedule		0.23							Fee Schedule											23.06							Fee Schedule		33.08							Fee Schedule		26.51							Fee Schedule		21.44							Fee Schedule											26.51							Fee Schedule		21.44							Fee Schedule		
SOLUMEDROL 40 MG/ML VIAL- SYRINGE PUMP	636	RC	J2919	CPT				Both			23.1	10.4	0.21	20.79		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	17.09							Fee Schedule		0.23							Fee Schedule											0.22							Fee Schedule		20.79							Fee Schedule		0.26							Fee Schedule		0.21							Fee Schedule											0.26							Fee Schedule		0.21							Fee Schedule		
SOLUMEDROL 500 MG INJECTION	636	RC	J2919	CPT				Both			61.95	27.88	0.21	55.76		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	45.84							Fee Schedule		0.23							Fee Schedule											0.22							Fee Schedule		55.76							Fee Schedule		0.26							Fee Schedule		0.21							Fee Schedule											0.26							Fee Schedule		0.21							Fee Schedule		
SOLYX BLUE SIS SYSTEM #M0068507010	278	RC	C1771	CPT				Both			3810	1714.5	0.21	3429		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	2819.4							Fee Schedule																				0.22							Fee Schedule		3429							Fee Schedule		0.26							Fee Schedule		0.21							Fee Schedule											0.26							Fee Schedule		0.21							Fee Schedule		
SOLYX SIS SYSTEM #M0068507000	278	RC	C1771	CPT				Both			3204.6	1442.07	0.21	2884.14		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	2371.4							Fee Schedule																				0.22							Fee Schedule		2884.14							Fee Schedule		0.26							Fee Schedule		0.21							Fee Schedule											0.26							Fee Schedule		0.21							Fee Schedule		
SOMATOSTATIN  34480	301	RC	84307	CPT				Both			312	140.4	0.21	280.8	16.24							Fee Schedule		20.31							Fee Schedule		18.83							Fee Schedule		18.28							Fee Schedule		0.22							Fee Schedule		280.8							Fee Schedule		0.26							Fee Schedule		0.21							Fee Schedule		18.28							Fee Schedule		0.26							Fee Schedule		0.21							Fee Schedule		
SONY COLOR PRINT PK. UPC 510  ( SENECA )	270	RC						Both			3.41	1.53	1.53	3.07	2.22							Fee Schedule		2.52							Fee Schedule																													3.07							Fee Schedule																																															
SONY COLOR PRINT PK. UPC 5510  STRYKER	270	RC						Both			6.3	2.84	2.84	5.67	4.1							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
SORBAVIEW SHIELD NANO SV118UDT	272	RC						Both			7	3.15	3.15	21.02	4.55							Fee Schedule		5.18							Fee Schedule																				18.28							Fee Schedule		6.3							Fee Schedule		21.02							Fee Schedule		17							Fee Schedule											21.02							Fee Schedule		17							Fee Schedule		
SORBITOL 70% 473ML BOTTLE	250	RC	A9270	CPT				Both			47.61	21.42	0.01	42.85	0.01							Fee Schedule		35.23							Fee Schedule																													42.85							Fee Schedule																																															
SORBSAN DSG EASH	272	RC						Both			8.66	3.9	3.9	7.79	5.63							Fee Schedule		6.41							Fee Schedule																													7.79							Fee Schedule																																															
SORE THROAT SPRAY	250	RC	A9270	CPT				Both			9.45	4.25	0.01	8.51	0.01							Fee Schedule		6.99							Fee Schedule																													8.51							Fee Schedule																																															
SOTALOL  80MG (BETAPACE) TABLET	250	RC	A9270	CPT				Both			8.4	3.78	0.01	7.56	0.01							Fee Schedule		6.22							Fee Schedule																													7.56							Fee Schedule																																															
SOTALOL 120MG (BETAPACE) TABLET	250	RC	A9270	CPT				Both			10.5	4.73	0.01	9.45	0.01							Fee Schedule		7.77							Fee Schedule																													9.45							Fee Schedule																																															
SOTRADECOL 3% INJ	250	RC						Both			295.05	132.77	132.77	265.55	191.78							Fee Schedule		218.34							Fee Schedule																													265.55							Fee Schedule																																															
SP TUBE INTRODUCER SET 20FR G15469	272	RC						Both			326	146.7	146.7	293.4	211.9							Fee Schedule		241.24							Fee Schedule																													293.4							Fee Schedule																																															
SPACER	250	RC	S8101	CPT				Both			60.3	27.14	5	54.27	5							Fee Schedule		44.62							Fee Schedule																													54.27							Fee Schedule																																															
SPADE-POINT WIRE 350 MM  SYNTHESE	278	RC						Both			127.05	57.17	57.17	114.35		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	94.02							Fee Schedule																													114.35							Fee Schedule																																															
SPARINE 50 MG/ML 2 ML AMP	636	RC	J2950	CPT				Both			22.3	10.04	10.04	20.07		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	16.5							Fee Schedule																													20.07							Fee Schedule																																															
SPATULA EPSO2	272	RC						Both			243.6	109.62	109.62	219.24	158.34							Fee Schedule		180.26							Fee Schedule																													219.24							Fee Schedule																																															
SPEC STAIN GROUP II	312	RC	88313	CPT				Both			179.55	80.8	38.44	161.6	38.44							Fee Schedule		55.07							Fee Schedule											62.67							Fee Schedule											161.6							Fee Schedule																																															
SPEC URINE COLLECTION KIT #DYND30212	272	RC						Both			3	1.35	1.35	2.7	1.95							Fee Schedule		2.22							Fee Schedule																													2.7							Fee Schedule																																															
SPECIAL STAINS GROUP I	312	RC	88312	CPT				Both			165.9	74.66	46.14	149.31	46.14							Fee Schedule		66.76							Fee Schedule											76.46							Fee Schedule											149.31							Fee Schedule																																															
SPECIFIC GRAVITY BODY FLUID	301	RC	84315	CPT				Both			23.1	10.4	2.36	20.79	2.36							Fee Schedule		3.28							Fee Schedule		3.38							Fee Schedule		3.28							Fee Schedule											20.79							Fee Schedule																				3.28							Fee Schedule																				
SPECIFIC GRAVITY URINE ONLY	307	RC	81003	CPT				Both			10.5	4.73	1.99	9.45	1.99							Fee Schedule		2.49							Fee Schedule		2.32							Fee Schedule		2.25							Fee Schedule											9.45							Fee Schedule																				2.25							Fee Schedule																				
SPEECH THERAPY	441	RC						Both			315	141.75	141.75	318	200							Per Diem		233.1							Fee Schedule																													283.5							Fee Schedule																				318							Per Diem																				
SPEEDBAND LIGATOR #M00542251	272	RC						Both			1966.65	884.99	3.05	1769.99	1278.32							Fee Schedule		1455.32							Fee Schedule																				3.28							Fee Schedule		1769.99							Fee Schedule		3.77							Fee Schedule		3.05							Fee Schedule											3.77							Fee Schedule		3.05							Fee Schedule		
SPERM ANTIBODIES SCREEN 19492	309	RC	89325	CPT				Both			169.29	76.18	2.09	152.36	9.49							Fee Schedule		11.86							Fee Schedule		10.99							Fee Schedule		10.67							Fee Schedule		2.25							Fee Schedule		152.36							Fee Schedule		2.59							Fee Schedule		2.09							Fee Schedule		10.67							Fee Schedule		2.59							Fee Schedule		2.09							Fee Schedule		
SPHINCTEROTOME 3-LUMEN KD-V411M-0730	272	RC	C1769	CPT				Both			365.4	164.43	154.26	328.86	154.26							Fee Schedule		270.4							Fee Schedule																													328.86							Fee Schedule																																															
SPIKEVAX COVID-19 VAX 50MCG SYRINGE	636	RC	91322	CPT				Both			466.2	209.79	166.5	419.58		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	344.99							Fee Schedule		166.5							Fee Schedule																				419.58							Fee Schedule																																															
SPINAL ANES TRAY 15545-20  SIMS	272	RC						Both			56	25.2	9.92	50.4	36.4							Fee Schedule		41.44							Fee Schedule																				10.67							Fee Schedule		50.4							Fee Schedule		12.27							Fee Schedule		9.92							Fee Schedule											12.27							Fee Schedule		9.92							Fee Schedule		
SPINAL ANES TRAY 333867	272	RC						Both			52	23.4	23.4	46.8	33.8							Fee Schedule		38.48							Fee Schedule																													46.8							Fee Schedule																																															
SPINAL NEEDLE 18X3.5  #405184	272	RC						Both			4	1.8	1.8	185.9	2.6							Fee Schedule		2.96							Fee Schedule																				161.65							Fee Schedule		3.6							Fee Schedule		185.9							Fee Schedule		150.34							Fee Schedule											185.9							Fee Schedule		150.34							Fee Schedule		
SPINAL NEEDLE 22G 7IN 405149	272	RC						Both			25	11.25	11.25	22.5	16.25							Fee Schedule		18.5							Fee Schedule																													22.5							Fee Schedule																																															
SPINAL NEEDLE 22G BRAUN  S2235	272	RC						Both			7	3.15	3.15	6.3	4.55							Fee Schedule		5.18							Fee Schedule																													6.3							Fee Schedule																																															
SPINAL NEEDLE 24G BRAUN  333884	272	RC						Both			12	5.4	5.4	10.8	7.8							Fee Schedule		8.88							Fee Schedule																													10.8							Fee Schedule																																															
SPINAL NEEDLE 25G 31/2IN BRAUN  333313	272	RC						Both			3	1.35	1.35	2.7	1.95							Fee Schedule		2.22							Fee Schedule																													2.7							Fee Schedule																																															
SPINAL NEEDLE 25G 411/16 #15545-20	272	RC						Both			48.3	21.74	21.74	43.47	31.4							Fee Schedule		35.74							Fee Schedule																													43.47							Fee Schedule																																															
SPINAL NEEDLE 25G 5IN 405140	272	RC						Both			43.76	19.69	19.69	39.38	28.44							Fee Schedule		32.38							Fee Schedule																													39.38							Fee Schedule																																															
SPINAL NEEDLE WHITACRE 22X3.5  405010	272	RC						Both			15.75	7.09	7.09	14.18	10.24							Fee Schedule		11.66							Fee Schedule																													14.18							Fee Schedule																																															
SPINAL NEEDLES 18X3 1/2 405184	272	RC						Both			4	1.8	1.8	3.6	2.6							Fee Schedule		2.96							Fee Schedule																													3.6							Fee Schedule																																															
SPINAL PUNCTURE LUMBAR DIAGNOSTIC			62270	CPT				Both			491.4	221.13	29.77	442.26	100.15							Fee Schedule		363.64							Fee Schedule											29.77							Fee Schedule											442.26							Fee Schedule																																															
SPINAL TRAY 15597-20	272	RC						Both			78	35.1	35.1	70.2	50.7							Fee Schedule		57.72							Fee Schedule																													70.2							Fee Schedule																																															
SPINE BENDING VIEWS 2-3V	320	RC	72120	CPT				Both			315	141.75	24.04	318	24.04							Fee Schedule		28.76							Fee Schedule											25.31							Fee Schedule											283.5							Fee Schedule																				318							Per Diem																				
SPINE SCOLIOSIS SURVEY	320	RC	72083	CPT				Both			315	141.75	36.46	318	46.46							Fee Schedule		53.12							Fee Schedule											36.46							Fee Schedule											283.5							Fee Schedule																				318							Per Diem																				
SPIRAL TIP 5FR	272	RC						Both			135.45	60.95	60.95	121.91	88.04							Fee Schedule		100.23							Fee Schedule																													121.91							Fee Schedule																																															
SPIRETTE MOUTHPIECE # 2050-5	271	RC						Both			9.45	4.25	4.25	8.51	6.14							Fee Schedule		6.99							Fee Schedule																													8.51							Fee Schedule																																															
SPIRIVA 18 MCG/CAPSULE HANDIHALER	250	RC	J3535	CPT				Both			302.4	136.08	136.08	272.16	196.56							Fee Schedule		223.78							Fee Schedule																													272.16							Fee Schedule																																															
SPIROMETRY CLINIC	460	RC	94010	CPT				Both			283.5	127.58	12.81	318	200							Per Diem		209.79							Fee Schedule											12.81							Fee Schedule											255.15							Fee Schedule																				318							Per Diem																				
SPIRONOLACTONE 25MG (ALDACTONE) TABLET	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
SPIRONOLACTONE 50MG (ALDACTONE) TABLET	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
SPLINTS POSTER TIBA	274	RC	L2116	CPT				Both			449.4	202.23	202.23	905.12		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	332.56							Fee Schedule		905.12							Fee Schedule		622.43							Fee Schedule											404.46							Fee Schedule																																															
SPLIT SHEET #DYNJP2499 (MEDLINE)	270	RC						Both			7	3.15	3.15	6.3	4.55							Fee Schedule		5.18							Fee Schedule																													6.3							Fee Schedule																																															
SPORANOX 10 MG/ML ORAL SOL.	250	RC	A9270	CPT				Both			343.35	154.51	0.01	309.02	0.01							Fee Schedule		254.08							Fee Schedule																													309.02							Fee Schedule																																															
SPORT KNEE CLOSED PATELLA LARGE	274	RC	A4565	CPT				Both			23.1	10.4	8.66	1010.57		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	17.09							Fee Schedule		11.31							Fee Schedule		8.66							Fee Schedule		878.76							Fee Schedule		20.79							Fee Schedule		1010.57							Fee Schedule		817.25							Fee Schedule											1010.57							Fee Schedule		817.25							Fee Schedule		
SPORT KNEE CLOSED PATELLA MEDIUM	274	RC	A4565	CPT				Both			23.1	10.4	8.66	20.79		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	17.09							Fee Schedule		11.31							Fee Schedule		8.66							Fee Schedule											20.79							Fee Schedule																																															
SPORT KNEE CLOSED PATELLA SMALL	274	RC	A4565	CPT				Both			23.1	10.4	8.66	20.79		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	17.09							Fee Schedule		11.31							Fee Schedule		8.66							Fee Schedule											20.79							Fee Schedule																																															
SPORT KNEE CLOSED PATELLA XLARGE	274	RC	A4565	CPT				Both			23.1	10.4	8.66	20.79		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	17.09							Fee Schedule		11.31							Fee Schedule		8.66							Fee Schedule		10.98							Fee Schedule		20.79							Fee Schedule		12.63							Fee Schedule		10.21							Fee Schedule											12.63							Fee Schedule		10.21							Fee Schedule		
SPORT KNEE LG OPEN 79-82707	274	RC	A4565	CPT				Both			26.25	11.81	8.66	23.63		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	19.43							Fee Schedule		11.31							Fee Schedule		8.66							Fee Schedule		10.98							Fee Schedule		23.63							Fee Schedule		12.63							Fee Schedule		10.21							Fee Schedule											12.63							Fee Schedule		10.21							Fee Schedule		
SPORT KNEE M OPEN 79-82705	274	RC	A4565	CPT				Both			26.25	11.81	8.66	23.63		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	19.43							Fee Schedule		11.31							Fee Schedule		8.66							Fee Schedule		10.98							Fee Schedule		23.63							Fee Schedule		12.63							Fee Schedule		10.21							Fee Schedule											12.63							Fee Schedule		10.21							Fee Schedule		
SPORT KNEE SM OPEN 79-82053	274	RC	A4565	CPT				Both			33.6	15.12	8.66	30.24		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	24.86							Fee Schedule		11.31							Fee Schedule		8.66							Fee Schedule		10.98							Fee Schedule		30.24							Fee Schedule		12.63							Fee Schedule		10.21							Fee Schedule											12.63							Fee Schedule		10.21							Fee Schedule		
SPORT KNEE XLG OPEN 79-82058	274	RC	A4565	CPT				Both			33.6	15.12	8.66	30.24		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	24.86							Fee Schedule		11.31							Fee Schedule		8.66							Fee Schedule		10.98							Fee Schedule		30.24							Fee Schedule		12.63							Fee Schedule		10.21							Fee Schedule											12.63							Fee Schedule		10.21							Fee Schedule		
SPORT KNEE XSM OPEN 79-82052	274	RC	A4565	CPT				Both			40.95	18.43	8.66	36.86		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	30.3							Fee Schedule		11.31							Fee Schedule		8.66							Fee Schedule		10.98							Fee Schedule		36.86							Fee Schedule		12.63							Fee Schedule		10.21							Fee Schedule											12.63							Fee Schedule		10.21							Fee Schedule		
SPORT KNEE XXLG OPEN 79-82059	274	RC	A4565	CPT				Both			33.6	15.12	8.66	30.24		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	24.86							Fee Schedule		11.31							Fee Schedule		8.66							Fee Schedule		10.98							Fee Schedule		30.24							Fee Schedule		12.63							Fee Schedule		10.21							Fee Schedule											12.63							Fee Schedule		10.21							Fee Schedule		
SPORT KNEE XXXLG OPEN 79-82709-10	274	RC	A4565	CPT				Both			33.6	15.12	8.66	30.24		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	24.86							Fee Schedule		11.31							Fee Schedule		8.66							Fee Schedule		10.98							Fee Schedule		30.24							Fee Schedule		12.63							Fee Schedule		10.21							Fee Schedule											12.63							Fee Schedule		10.21							Fee Schedule		
SPORTSWRAP DRESSING 9536	270	RC						Both			68.25	30.71	10.21	61.43	44.36							Fee Schedule		50.51							Fee Schedule																				10.98							Fee Schedule		61.43							Fee Schedule		12.63							Fee Schedule		10.21							Fee Schedule											12.63							Fee Schedule		10.21							Fee Schedule		
SPS SUSPENSION 30 GM/120 ML ENEMA/ ORAL	250	RC	A9270	CPT				Both			97.02	43.66	0.01	87.32	0.01							Fee Schedule		71.79							Fee Schedule																				10.98							Fee Schedule		87.32							Fee Schedule		12.63							Fee Schedule		10.21							Fee Schedule											12.63							Fee Schedule		10.21							Fee Schedule		
SPUR PAD	274	RC	L3485	CPT				Both			51.45	23.15	10.21	46.31		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	38.07							Fee Schedule																				10.98							Fee Schedule		46.31							Fee Schedule		12.63							Fee Schedule		10.21							Fee Schedule											12.63							Fee Schedule		10.21							Fee Schedule		
SPUTUM CULTURE COLLECTION	300	RC	89220	CPT				Both			63	28.35	10.65	162.74	10.65							Fee Schedule		14.8							Fee Schedule											16.9							Fee Schedule											56.7							Fee Schedule																				162.74							Fee Schedule																				
SPYGLASS DS AUTOLITH EHL PROBE M00546620	272	RC	C1889	CPT				Both			1287	579.15	579.15	1158.3	836.55							Fee Schedule		952.38							Fee Schedule																													1158.3							Fee Schedule																																															
SPYGLASS DS DELIVERY CATHETER M00546610	272	RC	C1889	CPT				Both			8268	3720.6	3720.6	7441.2	5374.2							Fee Schedule		6118.32							Fee Schedule																													7441.2							Fee Schedule																																															
SS BEADED SUTURE WIR	272	RC						Both			22.05	9.92	9.92	19.85	14.33							Fee Schedule		16.32							Fee Schedule																													19.85							Fee Schedule																																															
ST 2X2 SPLIT EACH	272	RC						Both			0.53	0.24	0.24	0.48	0.34							Fee Schedule		0.39							Fee Schedule																													0.48							Fee Schedule																																															
ST 4X4 SPLIT EACH	272	RC						Both			0.63	0.28	0.28	0.57	0.41							Fee Schedule		0.47							Fee Schedule																													0.57							Fee Schedule																																															
ST EHAVORIAL AND QUALITATIVE ANALYSIS V	442	RC	92524	CPT				Both			362.25	163.01	79.52	326.03	200							Per Diem		268.07							Fee Schedule											79.52							Fee Schedule											326.03							Fee Schedule																				318							Per Diem																				
ST EVAL OF SPEECH SOUND PRODUCTION	444	RC	92522	CPT				Both			351.75	158.29	77.02	318	200							Per Diem		260.3							Fee Schedule											77.02							Fee Schedule											316.58							Fee Schedule																				318							Per Diem																				
ST EVAL SPEECH SOUND PROD W/COMP	444	RC	92523	CPT				Both			724.5	326.03	159.52	652.05	200							Per Diem		536.13							Fee Schedule											159.52							Fee Schedule											652.05							Fee Schedule																				318							Per Diem																				
ST EVAL SWALLOWING	444	RC	92610	CPT				Both			320.25	144.11	32.48	318	200							Per Diem		236.99							Fee Schedule											32.48							Fee Schedule											288.23							Fee Schedule																				318							Per Diem																				
ST EVALUATION OF SPEECH FLUENCY	442	RC	92521	CPT				Both			430.5	193.73	94.51	387.45	200							Per Diem		318.57							Fee Schedule											94.51							Fee Schedule											387.45							Fee Schedule																				318							Per Diem																				
ST H20 1000	258	RC						Both			27.3	12.29	12.29	24.57	17.75							Fee Schedule		20.2							Fee Schedule																													24.57							Fee Schedule																																															
ST MOTION FLUOR EVAL SWALLOWING BY CINE	444	RC	92611	CPT				Both			341.25	153.56	35.36	318	200							Per Diem		252.53							Fee Schedule											35.36							Fee Schedule											307.13							Fee Schedule																				318							Per Diem																				
ST PROBE REVOLVE 8G/12CM #MST0812	272	RC						Both			1258	566.1	566.1	1132.2	817.7							Fee Schedule		930.92							Fee Schedule																													1132.2							Fee Schedule																																															
ST PROBE REVOLVE 8G/9CM #MST0809	272	RC						Both			1258	566.1	566.1	1132.2	817.7							Fee Schedule		930.92							Fee Schedule																													1132.2							Fee Schedule																																															
ST SPEECH LANG	442	RC	92507	CPT				Both			304.5	137.03	28.05	318	200							Per Diem		225.33							Fee Schedule											28.05							Fee Schedule											274.05							Fee Schedule																				318							Per Diem																				
ST TREAMENT SWALLOW	441	RC	92526	CPT				Both			336	151.2	32.09	318	200							Per Diem		248.64							Fee Schedule											32.09							Fee Schedule											302.4							Fee Schedule																				318							Per Diem																				
STADOL NASAL SPRAY	250	RC	S0012	CPT				Both			172.15	77.47	56.17	154.94	56.17							Fee Schedule		127.39							Fee Schedule																													154.94							Fee Schedule																																															
STAINLESS STEEL WIRE 18G.(CARDINAL)	270	RC						Both			84	37.8	37.8	75.6	54.6							Fee Schedule		62.16							Fee Schedule																													75.6							Fee Schedule																																															
STAINLESS STEEL WIRE 22G.(CARDINAL)	270	RC						Both			63	28.35	28.35	56.7	40.95							Fee Schedule		46.62							Fee Schedule																													56.7							Fee Schedule																																															
STALEVO 100 TABLET	250	RC	A9270	CPT				Both			8.4	3.78	0.01	7.56	0.01							Fee Schedule		6.22							Fee Schedule																													7.56							Fee Schedule																																															
STALEVO 150 TABLET UD	250	RC	A9270	CPT				Both			8.4	3.78	0.01	7.56	0.01							Fee Schedule		6.22							Fee Schedule																													7.56							Fee Schedule																																															
STANDARD 150 TUBE PLATE	278	RC						Both			826.35	371.86	371.86	743.72		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	611.5							Fee Schedule																													743.72							Fee Schedule																																															
STAPLE BOVIE MO65	272	RC						Both			81.9	36.86	36.86	73.71	53.24							Fee Schedule		60.61							Fee Schedule																													73.71							Fee Schedule																																															
START PACK GROUP CHARGE (OB)	272	RC						Both			18.9	8.51	8.51	17.01	12.29							Fee Schedule		13.99							Fee Schedule																													17.01							Fee Schedule																																															
STAT 5212 (DISC.)	270	RC						Both			14.7	6.62	6.62	13.23	9.56							Fee Schedule		10.88							Fee Schedule																													13.23							Fee Schedule																																															
STATLOCK FOLEY STABIL DEV FOL0102(BDMED)	272	RC						Both			9	4.05	4.05	8.1	5.85							Fee Schedule		6.66							Fee Schedule																													8.1							Fee Schedule																																															
STATLOCK STABILIZATION DEVICE VUPD1012	272	RC						Both			28	12.6	12.6	25.2	18.2							Fee Schedule		20.72							Fee Schedule																													25.2							Fee Schedule																																															
STATLOCK UNIVERSAL   1837-2100 (CONCOR)	272	RC						Both			14.44	6.5	6.5	13	9.39							Fee Schedule		10.69							Fee Schedule																													13							Fee Schedule																																															
STAYFIX FIXATION DEVICE 5-14FR 680ME	272	RC	A5200	CPT				Both			29	13.05	10.18	26.1	10.18							Fee Schedule		21.46							Fee Schedule		16.6							Fee Schedule																				26.1							Fee Schedule																																															
STELARA 130MG/26ML SDV	636	RC	J3358	CPT				Both			7288.23	3279.7	11.63	6559.41		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	11.63							Fee Schedule		12.86							Fee Schedule																				6559.41							Fee Schedule																																															
STELARA 130MG/NS 250ML	636	RC	J3358	CPT				Both			7288.23	3279.7	11.63	6559.41		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	11.63							Fee Schedule		12.86							Fee Schedule																				6559.41							Fee Schedule																																															
STELARA 390MG/NS 250ML	636	RC	J3358	CPT				Both			21864.69	9839.11	11.63	19678.22		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	11.63							Fee Schedule		12.86							Fee Schedule											16.12							Fee Schedule		19678.22							Fee Schedule		18.54							Fee Schedule		14.99							Fee Schedule											18.54							Fee Schedule		14.99							Fee Schedule		
STELAZINE 2 MG TABLET	250	RC	A9270	CPT				Both			2.3	1.04	0.01	14.36	0.01							Fee Schedule		1.7							Fee Schedule																				12.49							Fee Schedule		2.07							Fee Schedule		14.36							Fee Schedule		11.62							Fee Schedule											14.36							Fee Schedule		11.62							Fee Schedule		
STELLATE BLOCK			64510	CPT				Both			315	141.75	11.62	283.5	95.01							Fee Schedule		233.1							Fee Schedule																				12.49							Fee Schedule		283.5							Fee Schedule		14.36							Fee Schedule		11.62							Fee Schedule											14.36							Fee Schedule		11.62							Fee Schedule		
STENT GRAFT SYSTEM AORTIC #ETTF2323C70E	278	RC	C1876	CPT				Both			23546.25	10595.81	11.62	21191.63		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	17424.23							Fee Schedule																				12.49							Fee Schedule		21191.63							Fee Schedule		14.36							Fee Schedule		11.62							Fee Schedule											14.36							Fee Schedule		11.62							Fee Schedule		
STENT GRAFT SYSTEM BIFURC #ESBF3214C103E	278	RC	C1876	CPT				Both			31421.25	14139.56	14139.56	28279.13		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	23251.73							Fee Schedule																													28279.13							Fee Schedule																																															
STENT GRAFT SYSTEM BIFURC #ESBF3614C103E	278	RC	C1876	CPT				Both			31122	14004.9	14004.9	28009.8		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	23030.28							Fee Schedule																													28009.8							Fee Schedule																																															
STENT GRAFT SYSTEM BIFURC #ETBF2813C145E	278	RC	C1876	CPT				Both			31421.25	14139.56	14139.56	28279.13		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	23251.73							Fee Schedule																													28279.13							Fee Schedule																																															
STENT GRAFT SYSTEM BIFURC #ETBF2816C166E	278	RC	C1876	CPT				Both			31122	14004.9	14004.9	28009.8		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	23030.28							Fee Schedule																													28009.8							Fee Schedule																																															
STENT GRAFT SYSTEM ESBF3214C103E	278	RC	C1876	CPT				Both			31421.25	14139.56	14139.56	28279.13		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	23251.73							Fee Schedule																													28279.13							Fee Schedule																																															
STENT GRAFT SYSTEM ETLW1610C124E	278	RC	C1876	CPT				Both			14925	6716.25	6716.25	13432.5		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	11044.5							Fee Schedule																													13432.5							Fee Schedule																																															
STENT GRAFT SYSTEM ETLW1610C146E	278	RC	C1876	CPT				Both			19200	8640	8640	17280		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	14208							Fee Schedule																													17280							Fee Schedule																																															
STENT GRAFT SYSTEM ILIAC #ETEW1313C82E	278	RC	C1876	CPT				Both			14647.5	6591.38	6591.38	13182.75		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	10839.15							Fee Schedule																													13182.75							Fee Schedule																																															
STENT GRAFT SYSTEM ILIAC #ETEW2020C82E	278	RC	C1876	CPT				Both			15277.5	6874.88	6874.88	13749.75		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	11305.35							Fee Schedule																													13749.75							Fee Schedule																																															
STENT GRAFT SYSTEM ILIAC #ETEW2424C82E	278	RC	C1876	CPT				Both			15513.75	6981.19	6981.19	13962.38		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	11480.18							Fee Schedule																													13962.38							Fee Schedule																																															
STENT GRAFT SYSTEM LIMB #ETLW1610C93E	278	RC	C1876	CPT				Both			14775	6648.75	6648.75	13297.5		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	10933.5							Fee Schedule																													13297.5							Fee Schedule																																															
STENT GRAFT SYSTEM LIMB #ETLW1613C156E	278	RC	C1876	CPT				Both			19968	8985.6	8985.6	17971.2		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	14776.32							Fee Schedule																													17971.2							Fee Schedule																																															
STENT GRAFT SYSTEM LIMB #ETLW1613C199E	278	RC	C1876	CPT				Both			19485	8768.25	8768.25	17536.5		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	14418.9							Fee Schedule																													17536.5							Fee Schedule																																															
STENT GRAFT SYSTEM LIMB #ETLW1613C93E	278	RC	C1876	CPT				Both			14775	6648.75	6648.75	13297.5		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	10933.5							Fee Schedule																													13297.5							Fee Schedule																																															
STENT GRAFT SYSTEM LIMB #ETLW1616C124E	278	RC	C1876	CPT				Both			15513.75	6981.19	6981.19	13962.38		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	11480.18							Fee Schedule																													13962.38							Fee Schedule																																															
STENT GRAFT SYSTEM LIMB #ETLW1620C93E	278	RC	C1876	CPT				Both			14775	6648.75	6648.75	13297.5		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	10933.5							Fee Schedule																													13297.5							Fee Schedule																																															
STENT GRAFT SYSTEM LIMB #ETLW1624C124E	278	RC	C1876	CPT				Both			15671.25	7052.06	7052.06	14104.13		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	11596.73							Fee Schedule																													14104.13							Fee Schedule																																															
STENT GRAFT SYSTEM LIMB #ETLW1624C146E	278	RC	C1876	CPT				Both			19200	8640	8640	17280		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	14208							Fee Schedule																													17280							Fee Schedule																																															
STENT GRAFT SYSTEM LIMB #ETLW1624C93E	278	RC	C1876	CPT				Both			15671.25	7052.06	7052.06	14104.13		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	11596.73							Fee Schedule																													14104.13							Fee Schedule																																															
STENT GRAFT SYSTEM LIMB #ETLW1628C124E	278	RC	C1876	CPT				Both			15671.25	7052.06	7052.06	14104.13		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	11596.73							Fee Schedule																													14104.13							Fee Schedule																																															
STENT GRAFT SYSTEM LIMB ESBF2814C103E	278	RC	C1876	CPT				Both			30000	13500	13500	27000		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	22200							Fee Schedule																													27000							Fee Schedule																																															
STENT INTRODUCER OA-8.5	272	RC						Both			214.2	96.39	96.39	192.78	139.23							Fee Schedule		158.51							Fee Schedule																													192.78							Fee Schedule																																															
STENT PERIPHERAL VISI-PRO PXB35-05-17-08	278	RC	C1876	CPT				Both			3120	1404	1404	2808		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	2308.8							Fee Schedule																													2808							Fee Schedule																																															
STENT PERIPHERAL VISI-PRO PXB35-06-17-08	278	RC	C1876	CPT				Both			3119	1403.55	1403.55	2807.1		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	2308.06							Fee Schedule																													2807.1							Fee Schedule																																															
STENT PERIPHERAL VISI-PRO PXB35-07-12-08	278	RC	C1876	CPT				Both			3120	1404	1404	2808		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	2308.8							Fee Schedule																													2808							Fee Schedule																																															
STENT PERIPHERAL VISI-PRO PXB35-07-27-08	278	RC	C1876	CPT				Both			3119	1403.55	1403.55	2807.1		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	2308.06							Fee Schedule																													2807.1							Fee Schedule																																															
STENT PERIPHERAL VISI-PRO PXB35-07-37-08	278	RC	C1876	CPT				Both			3119	1403.55	1403.55	2807.1		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	2308.06							Fee Schedule																													2807.1							Fee Schedule																																															
STENT PERIPHERAL VISI-PRO PXB35-08-17-08	278	RC	C1876	CPT				Both			3119	1403.55	1403.55	2807.1		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	2308.06							Fee Schedule																													2807.1							Fee Schedule																																															
STENT PERIPHERAL VISI-PRO PXB35-09-57-08	278	RC	C1876	CPT				Both			3119	1403.55	1403.55	2807.1		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	2308.06							Fee Schedule																													2807.1							Fee Schedule																																															
STENT PERIPHERAL VISI-PRO PXB35-10-37-08	278	RC	C1876	CPT				Both			4800	2160	2160	4320		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	3552							Fee Schedule																													4320							Fee Schedule																																															
STENT POLYFLEX # 1428 ( MICROVASIVE	278	RC	C1877	CPT				Both			6741	3033.45	3033.45	6066.9		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	4988.34							Fee Schedule																													6066.9							Fee Schedule																																															
STENT SYSTEM ILIAC/BILI. H74938046730750	278	RC	C1876	CPT				Both			2205	992.25	992.25	1984.5		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1631.7							Fee Schedule																													1984.5							Fee Schedule																																															
STENT SYSTEM ILIAC/BILI. H74938046940750	278	RC	C1876	CPT				Both			2205	992.25	992.25	1984.5		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1631.7							Fee Schedule																													1984.5							Fee Schedule																																															
STENT SYSTEM ILIAC/BILI. H74938047820130	278	RC	C1876	CPT				Both			2205	992.25	992.25	1984.5		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1631.7							Fee Schedule																													1984.5							Fee Schedule																																															
STENT SYSTEM ILIAC/BILI. H74938047860130	278	RC	C1876	CPT				Both			2205	992.25	992.25	1984.5		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1631.7							Fee Schedule																													1984.5							Fee Schedule																																															
STEREO LOCALIZATION 1ST	320	RC	19283	CPT				Both			2100	945	110.75	1890	110.75							Fee Schedule		1554							Fee Schedule																													1890							Fee Schedule																				318							Per Diem																				
STEREO LOCALIZATION ADDITIONAL	320	RC	19284	CPT				Both			2100	945	55.9	1890	55.9							Fee Schedule		1554							Fee Schedule																													1890							Fee Schedule																				318							Per Diem																				
STERI H20 IRRIG 1000	258	RC						Both			34.65	15.59	15.59	31.19	22.52							Fee Schedule		25.64							Fee Schedule																													31.19							Fee Schedule																																															
STERI STRIPS 1/2 INCH #NON250412Z	272	RC						Both			1	0.45	0.45	0.9	0.65							Fee Schedule		0.74							Fee Schedule																													0.9							Fee Schedule																																															
STERI STRIPS 1/4 INCH #NON250314Z	272	RC						Both			1	0.45	0.45	0.9	0.65							Fee Schedule		0.74							Fee Schedule																													0.9							Fee Schedule																																															
STERI-CATH CLOSED VENTILATION SUCTION	272	RC						Both			49.35	22.21	22.21	44.42	32.08							Fee Schedule		36.52							Fee Schedule																													44.42							Fee Schedule																																															
STERI-CUFF DB	272	RC						Both			128.1	57.65	57.65	115.29	83.27							Fee Schedule		94.79							Fee Schedule																													115.29							Fee Schedule																																															
STERI-CUFF SB	272	RC						Both			71.4	32.13	32.13	64.26	46.41							Fee Schedule		52.84							Fee Schedule																													64.26							Fee Schedule																																															
STERIDRAPE 1010	272	RC						Both			3.15	1.42	1.42	2.84	2.05							Fee Schedule		2.33							Fee Schedule																													2.84							Fee Schedule																																															
STERIDRAPE 1012 35  X 43  INSPIRE	272	RC						Both			13	5.85	5.85	11.7	8.45							Fee Schedule		9.62							Fee Schedule																													11.7							Fee Schedule																																															
STERIDRAPE 1015	272	RC						Both			9	4.05	4.05	8.1	5.85							Fee Schedule		6.66							Fee Schedule																													8.1							Fee Schedule																																															
STERIDRAPE 1020	272	RC						Both			12.6	5.67	5.67	11.34	8.19							Fee Schedule		9.32							Fee Schedule																													11.34							Fee Schedule																																															
STERIDRAPE 1050 (SENECA)	272	RC						Both			8	3.6	3.6	7.2	5.2							Fee Schedule		5.92							Fee Schedule																													7.2							Fee Schedule																																															
STERIDRAPE 1092	272	RC						Both			5.25	2.36	2.36	4.73	3.41							Fee Schedule		3.89							Fee Schedule																													4.73							Fee Schedule																																															
STERILE 0.9% NACL FOR IRRIGATION 3000ML	272	RC	A4217	CPT				Both			32.55	14.65	2.4	29.3	2.4							Fee Schedule		24.09							Fee Schedule		3.91							Fee Schedule																				29.3							Fee Schedule																																															
STERILE 2X2 #NON21224 OR #8042	272	RC						Both			3	1.35	1.35	2.7	1.95							Fee Schedule		2.22							Fee Schedule																													2.7							Fee Schedule																																															
STERILE 2X2 EACH	272	RC						Both			0.16	0.07	0.07	0.14	0.1							Fee Schedule		0.12							Fee Schedule																													0.14							Fee Schedule																																															
STERILE 4X4  6939 (OR)	272	RC						Both			2	0.9	0.9	4.37	1.3							Fee Schedule		1.48							Fee Schedule																				3.8							Fee Schedule		1.8							Fee Schedule		4.37							Fee Schedule		3.53							Fee Schedule											4.37							Fee Schedule		3.53							Fee Schedule		
STERILE 4X4 10PK 2539 (OR)	272	RC						Both			3	1.35	1.35	2.7	1.95							Fee Schedule		2.22							Fee Schedule																													2.7							Fee Schedule																																															
STERILE 4X4 5PKG #NON21444	272	RC						Both			1	0.45	0.45	0.9	0.65							Fee Schedule		0.74							Fee Schedule																													0.9							Fee Schedule																																															
STERILE 4X4 DRESS	272	RC						Both			1.05	0.47	0.47	0.95	0.68							Fee Schedule		0.78							Fee Schedule																													0.95							Fee Schedule																																															
STERILE 4X4 EACH	272	RC						Both			0.42	0.19	0.19	0.38	0.27							Fee Schedule		0.31							Fee Schedule																													0.38							Fee Schedule																																															
STERILE 4X4 H.H	270	RC						Both			7.35	3.31	3.31	6.62	4.78							Fee Schedule		5.44							Fee Schedule																													6.62							Fee Schedule																																															
STERILE BURN SHEETS	272	RC						Both			26.25	11.81	11.81	23.63	17.06							Fee Schedule		19.43							Fee Schedule																													23.63							Fee Schedule																																															
STERILE CONTAINER	272	RC						Both			1.05	0.47	0.47	0.95	0.68							Fee Schedule		0.78							Fee Schedule																													0.95							Fee Schedule																																															
STERILE GLOVES 6 133600 (PURCHASING)	272	RC						Both			2	0.9	0.9	1.8	1.3							Fee Schedule		1.48							Fee Schedule																													1.8							Fee Schedule																																															
STERILE GLOVES 6.5 133650 (PURCHASING)	270	RC						Both			1.68	0.76	0.76	1.51	1.09							Fee Schedule		1.24							Fee Schedule																													1.51							Fee Schedule																																															
STERILE GLOVES 7 133700 (PURCHASING)	272	RC						Both			2	0.9	0.9	1.8	1.3							Fee Schedule		1.48							Fee Schedule																													1.8							Fee Schedule																																															
STERILE GLOVES 7.5 133750 (PURCHASING)	270	RC						Both			1.05	0.47	0.47	0.95	0.68							Fee Schedule		0.78							Fee Schedule																													0.95							Fee Schedule																																															
STERILE GLOVES 8 133800 (PURCHASING)	272	RC						Both			2	0.9	0.9	1.8	1.3							Fee Schedule		1.48							Fee Schedule																													1.8							Fee Schedule																																															
STERILE GLOVES 8.5 133850 (PURCHASING)	272	RC						Both			2	0.9	0.9	1.8	1.3							Fee Schedule		1.48							Fee Schedule																													1.8							Fee Schedule																																															
STERILE RULER #DYNJRULER	272	RC						Both			3	1.35	1.35	2.7	1.95							Fee Schedule		2.22							Fee Schedule																													2.7							Fee Schedule																																															
STERILE SLEEVES (MEDLINE) #DYNJP2000A	272	RC						Both			2	0.9	0.9	1.8	1.3							Fee Schedule		1.48							Fee Schedule																													1.8							Fee Schedule																																															
STERILE STRIP 1/4	272	RC						Both			4.2	1.89	1.89	3.78	2.73							Fee Schedule		3.11							Fee Schedule																													3.78							Fee Schedule																																															
STERILE SUTURE REMOV	272	RC						Both			5.25	2.36	2.36	4.73	3.41							Fee Schedule		3.89							Fee Schedule																													4.73							Fee Schedule																																															
STERILE WATER 1000CC BAGS UROL. #2B7114X	270	RC	A4217	CPT				Both			8.4	3.78	2.4	7.56	2.4							Fee Schedule		6.22							Fee Schedule		3.91							Fee Schedule																				7.56							Fee Schedule																																															
STERILE WATER 1000ML INHAL. 7871800000	272	RC						Both			11	4.95	4.95	9.9	7.15							Fee Schedule		8.14							Fee Schedule																													9.9							Fee Schedule																																															
STERILE WATER FOR INJECTION 20ML VIAL	636	RC	A9270	CPT				Both			21.78	9.8	9.8	19.6		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	16.12							Fee Schedule																													19.6							Fee Schedule																																															
STERILE WATER FOR INJECTION 500 ML	636	RC	A4217	CPT				Both			12.81	5.76	3.53	11.53		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	9.48							Fee Schedule		3.91							Fee Schedule											3.8							Fee Schedule		11.53							Fee Schedule		4.37							Fee Schedule		3.53							Fee Schedule											4.37							Fee Schedule		3.53							Fee Schedule		
STERILE WATER FOR INJECTION 50ML VIAL	636	RC	A9270	CPT				Both			31.74	14.28	14.28	28.57		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	23.49							Fee Schedule																													28.57							Fee Schedule																																															
STERILE WATER FOR IRRIGATION 3000ML	636	RC	A4217	CPT				Both			27.3	12.29	3.91	24.57		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	20.2							Fee Schedule		3.91							Fee Schedule																				24.57							Fee Schedule																																															
STERILE WATER IRRIGATION 2000ML #2B7116	270	RC	A4217	CPT				Both			14.7	6.62	2.4	13.23	2.4							Fee Schedule		10.88							Fee Schedule		3.91							Fee Schedule											3.8							Fee Schedule		13.23							Fee Schedule		4.37							Fee Schedule		3.53							Fee Schedule											4.37							Fee Schedule		3.53							Fee Schedule		
STERILE WATER IRRIGATION 500ML #2F7113	272	RC	A4217	CPT				Both			6	2.7	2.4	5.4	2.4							Fee Schedule		4.44							Fee Schedule		3.91							Fee Schedule																				5.4							Fee Schedule																																															
STERILE WEBRIL 2  2283	272	RC						Both			1	0.45	0.45	4.37	0.65							Fee Schedule		0.74							Fee Schedule																				3.8							Fee Schedule		0.9							Fee Schedule		4.37							Fee Schedule		3.53							Fee Schedule											4.37							Fee Schedule		3.53							Fee Schedule		
STERILE WEBRIL 4  2502	272	RC						Both			3	1.35	1.35	4.37	1.95							Fee Schedule		2.22							Fee Schedule																				3.8							Fee Schedule		2.7							Fee Schedule		4.37							Fee Schedule		3.53							Fee Schedule											4.37							Fee Schedule		3.53							Fee Schedule		
STERILE WEBRIL 6  2944	272	RC						Both			12.6	5.67	3.53	11.34	8.19							Fee Schedule		9.32							Fee Schedule																				3.8							Fee Schedule		11.34							Fee Schedule		4.37							Fee Schedule		3.53							Fee Schedule											4.37							Fee Schedule		3.53							Fee Schedule		
STERITALC 4GM (STERILE TALC POWDER) VIAL	250	RC	A9270	CPT				Both			469.35	211.21	0.01	422.42	0.01							Fee Schedule		347.32							Fee Schedule																													422.42							Fee Schedule																																															
STERNUM	320	RC	71120	CPT				Both			315	141.75	15.89	318	15.89							Fee Schedule		19.02							Fee Schedule											18.57							Fee Schedule											283.5							Fee Schedule																				318							Per Diem																				
STETHOSCOPE DISPOSABLE #665Y	270	RC						Both			3	1.35	1.35	2.7	1.95							Fee Schedule		2.22							Fee Schedule																													2.7							Fee Schedule																																															
STIMULATION GROUND CABLE #9003	272	RC						Both			138	62.1	62.1	124.2	89.7							Fee Schedule		102.12							Fee Schedule																													124.2							Fee Schedule																																															
STIMULATION PROBE 85MM #525608	272	RC						Both			330	148.5	148.5	297	214.5							Fee Schedule		244.2							Fee Schedule																													297							Fee Schedule																																															
STIMUQUIK INSULATED  NEEDLE AB-21090-SSE	272	RC	A4215	CPT				Both			38	17.1	0.13	34.2	0.15							Fee Schedule		28.12							Fee Schedule											0.13							Fee Schedule											34.2							Fee Schedule																																															
STIRRUP ANKLE BRACE	274	RC	L1990	CPT				Both			61.95	27.88	27.88	558.12		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	45.84							Fee Schedule		558.12							Fee Schedule		427.94							Fee Schedule											55.76							Fee Schedule																																															
STOCKINETTE 2 INCH 81220	270	RC						Both			14.7	6.62	6.62	13.23	9.56							Fee Schedule		10.88							Fee Schedule																													13.23							Fee Schedule																																															
STOCKINETTE 8  81820	270	RC	A6457	CPT				Both			80	36	1.02	72	1.02							Fee Schedule		59.2							Fee Schedule		1.67							Fee Schedule																				72							Fee Schedule																																															
STOCKINETTE LG STERILE #9816-54 DEROYAL	272	RC						Both			13	5.85	5.85	623.14	8.45							Fee Schedule		9.62							Fee Schedule																				541.86							Fee Schedule		11.7							Fee Schedule		623.14							Fee Schedule		503.93							Fee Schedule											623.14							Fee Schedule		503.93							Fee Schedule		
STOMACH RELIEF (PEPTO BISMOL) SUSP-473ML	250	RC	A9270	CPT				Both			26.97	12.14	0.01	24.27	0.01							Fee Schedule		19.96							Fee Schedule																													24.27							Fee Schedule																																															
"ALCOHOL, DRUG ABUSE OR DEPENDENCE, LEFT AMA"					894	DRG		Inpatient			11259.2	5066.64	5066.64	5066.64							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0	Fee Schedule	No services provided during 15 month lookback period							0	Fee Schedule	No services provided during 15 month lookback period							0		No services provided during 15 month lookback							0		No services provided during 15 month lookback period							0	Fee Schedule	No services provided during 15 month lookback period	
"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THE"					896	DRG		Inpatient			55729.76	25078.39	25078.39	25078.39							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period							0		No services provided during 15 month lookback period				1271.6	1271.6	1271.6	1 through 10									0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback				155.41	155.41	155.41	1 through 10									0		No services provided during 15 month lookback period	
"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THE"					897	DRG		Inpatient			19025.93	8561.67	8561.67	8561.67							0		No services performed during 15 month lookback period. 				4746.59	4746.59	4746.59	1 through 10									0		No services performed during 15 month lookback period				2281.05	2281.05	2281.05	1 through 10									0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period	
STOMAFOAM SQ	272	RC						Both			30.71	13.82	13.82	27.64	19.96							Fee Schedule		22.73							Fee Schedule																													27.64							Fee Schedule																																															
STONE ANALYSIS QUALITATIVE	301	RC	82355	CPT				Both			85.05	38.27	10.29	76.55	10.29							Fee Schedule		12.86							Fee Schedule		11.93							Fee Schedule		11.58							Fee Schedule											76.55							Fee Schedule																				11.58							Fee Schedule																				
STONE ANALYSIS QUANTITATIVE	301	RC	82360	CPT				Both			111.3	50.09	11.44	100.17	11.44							Fee Schedule		14.3							Fee Schedule		13.26							Fee Schedule		12.87							Fee Schedule											100.17							Fee Schedule																				12.87							Fee Schedule																				
STONE RETREIVAL 4 WI	272	RC						Both			573.3	257.99	257.99	515.97	372.65							Fee Schedule		424.24							Fee Schedule																													515.97							Fee Schedule																																															
STONE RETRIEVAL 6 WI	272	RC						Both			573.3	257.99	10.77	515.97	372.65							Fee Schedule		424.24							Fee Schedule																				11.58							Fee Schedule		515.97							Fee Schedule		13.32							Fee Schedule		10.77							Fee Schedule											13.32							Fee Schedule		10.77							Fee Schedule		
STOOL CHLORIDE 883110 ML STOOL FRZ	301	RC	82438	CPT				Both			126	56.7	4.34	113.4	4.34							Fee Schedule		5.43							Fee Schedule		5.15							Fee Schedule		5							Fee Schedule		12.87							Fee Schedule		113.4							Fee Schedule		14.8							Fee Schedule		11.97							Fee Schedule		5							Fee Schedule		14.8							Fee Schedule		11.97							Fee Schedule		
STOOL CHYMOTRYPSIN 11235 1G STOOL FRZ	301	RC	84311	CPT				Both			239.4	107.73	6.21	215.46	6.21							Fee Schedule		8.1							Fee Schedule		8.34							Fee Schedule		8.1							Fee Schedule											215.46							Fee Schedule																				8.1							Fee Schedule																				
STOOL FOR REDUCING SUBSTANCE 5022	301	RC	84376	CPT				Both			133.35	60.01	4.89	120.02	4.89							Fee Schedule		6.11							Fee Schedule		5.67							Fee Schedule		5.5							Fee Schedule											120.02							Fee Schedule																				5.5							Fee Schedule																				
STOOL O & P 681 SPECIAL CONTAINER	300	RC	87177	CPT				Both			52.5	23.63	4.65	47.25	7.91							Fee Schedule		9.89							Fee Schedule		9.17							Fee Schedule		8.9							Fee Schedule		5							Fee Schedule		47.25							Fee Schedule		5.75							Fee Schedule		4.65							Fee Schedule		8.9							Fee Schedule		5.75							Fee Schedule		4.65							Fee Schedule		
STOOL OSMOLARITY 968	301	RC	84999	CPT				Both			133.35	60.01	7.53	120.02	86.68							Fee Schedule									Other	No Additional Reimbursement 																			8.1							Fee Schedule		120.02							Fee Schedule		9.32							Fee Schedule		7.53							Fee Schedule											9.32							Fee Schedule		7.53							Fee Schedule		
STOOL PANCREATIC ELASTACE 1  14693	301	RC	82656	CPT				Both			373.8	168.21	5.12	336.42	10.25							Fee Schedule		12.81							Fee Schedule		11.88							Fee Schedule		11.53							Fee Schedule		5.5							Fee Schedule		336.42							Fee Schedule		6.33							Fee Schedule		5.12							Fee Schedule		11.53							Fee Schedule		6.33							Fee Schedule		5.12							Fee Schedule		
STOOL PH 1304	301	RC	83986	CPT				Both			103.95	46.78	3.18	93.56	3.18							Fee Schedule		3.98							Fee Schedule		3.69							Fee Schedule		3.58							Fee Schedule		8.9							Fee Schedule		93.56							Fee Schedule		10.24							Fee Schedule		8.28							Fee Schedule		3.58							Fee Schedule		10.24							Fee Schedule		8.28							Fee Schedule		
STOOL POTASSIUM 8832	301	RC	84999	CPT				Both			269.85	121.43	121.43	242.87	175.4							Fee Schedule									Other	No Additional Reimbursement 																												242.87							Fee Schedule																																															
STOOL SODIUM 8833	301	RC	84999	CPT				Both			269.85	121.43	10.72	242.87	175.4							Fee Schedule									Other	No Additional Reimbursement 																			11.53							Fee Schedule		242.87							Fee Schedule		13.26							Fee Schedule		10.72							Fee Schedule											13.26							Fee Schedule		10.72							Fee Schedule		
STOOL WBC 3930 SPECIAL COLLECTION	305	RC	85008	CPT				Both			38.85	17.48	3.05	34.97	3.05							Fee Schedule		3.82							Fee Schedule		3.53							Fee Schedule		3.43							Fee Schedule		3.58							Fee Schedule		34.97							Fee Schedule		4.12							Fee Schedule		3.33							Fee Schedule		3.43							Fee Schedule		4.12							Fee Schedule		3.33							Fee Schedule		
STOOL WBC'S LACTOFERRIN	301	RC	83630	CPT				Both			110.25	49.61	17.45	99.23	17.45							Fee Schedule		21.81							Fee Schedule		20.29							Fee Schedule		19.7							Fee Schedule											99.23							Fee Schedule																				19.7							Fee Schedule																				
STOP COCKS PER BOX	272	RC						Both			68.25	30.71	30.71	61.43	44.36							Fee Schedule		50.51							Fee Schedule																													61.43							Fee Schedule																																															
STOPCOCK 3 WAY ( OR )  622500	272	RC						Both			19	8.55	3.19	17.1	12.35							Fee Schedule		14.06							Fee Schedule																				3.43							Fee Schedule		17.1							Fee Schedule		3.94							Fee Schedule		3.19							Fee Schedule											3.94							Fee Schedule		3.19							Fee Schedule		
STOPCOCK 3WAY #MX5311L	272	RC						Both			2	0.9	0.9	22.66	1.3							Fee Schedule		1.48							Fee Schedule																				19.7							Fee Schedule		1.8							Fee Schedule		22.66							Fee Schedule		18.32							Fee Schedule											22.66							Fee Schedule		18.32							Fee Schedule		
STRAIGHT CONNECTOR 22MM ID X 22MM ID	270	RC						Both			1	0.45	0.45	0.9	0.65							Fee Schedule		0.74							Fee Schedule																													0.9							Fee Schedule																																															
STRATAFIX 0 12  SXPP1B450	272	RC						Both			74	33.3	33.3	66.6	48.1							Fee Schedule		54.76							Fee Schedule																													66.6							Fee Schedule																																															
STRATAFIX 0 24CMX24CM SXPD2B415	272	RC						Both			61.95	27.88	27.88	55.76	40.27							Fee Schedule		45.84							Fee Schedule																													55.76							Fee Schedule																																															
STRATAFIX 0 9  SXPP1B455 J&J	272	RC						Both			75	33.75	33.75	67.5	48.75							Fee Schedule		55.5							Fee Schedule																													67.5							Fee Schedule																																															
STRATAFIX 0 PDS PLUS SXPP1A446	272	RC						Both			80	36	36	72	52							Fee Schedule		59.2							Fee Schedule																													72							Fee Schedule																																															
STRATAFIX 1.0 36CMX36CM SXPD2B202	272	RC						Both			59.85	26.93	26.93	53.87	38.9							Fee Schedule		44.29							Fee Schedule																													53.87							Fee Schedule																																															
STRATAFIX 1-0 PDS PLUS SXMP1B409	272	RC						Both			57	25.65	25.65	51.3	37.05							Fee Schedule		42.18							Fee Schedule																													51.3							Fee Schedule																																															
STRATAFIX 1-0 PDS PLUS SXPP1A435  J&J	272	RC						Both			80	36	36	72	52							Fee Schedule		59.2							Fee Schedule																													72							Fee Schedule																																															
STRATAFIX 2-0 PDS PLUS SXPP1A431 J&J	272	RC						Both			81.9	36.86	36.86	73.71	53.24							Fee Schedule		60.61							Fee Schedule																													73.71							Fee Schedule																																															
STRATAFIX 3-0 PDS PLUS SXPP1A413	272	RC						Both			88.2	39.69	39.69	79.38	57.33							Fee Schedule		65.27							Fee Schedule																													79.38							Fee Schedule																																															
STRATAFIX 3-0 SPIRAL MONOCRYL SXMP1B107	272	RC						Both			91	40.95	40.95	81.9	59.15							Fee Schedule		67.34							Fee Schedule																													81.9							Fee Schedule																																															
STRATAFIX SYMMETRIC PDS SXPP1A404	272	RC						Both			63	28.35	28.35	56.7	40.95							Fee Schedule		46.62							Fee Schedule																													56.7							Fee Schedule																																															
STRATIFY JCV AB WITH RELX 91665	300	RC	86711	CPT				Both			2726	1226.7	12.79	2453.4	12.79							Fee Schedule		16.89							Fee Schedule		17.4							Fee Schedule		16.89							Fee Schedule											2453.4							Fee Schedule																				16.89							Fee Schedule																				
STRATTICE (LIFE CELL) MESH 1010002	278	RC	Q4130	CPT				Both			9903.6	4456.62	130.95	8913.24		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	7328.66							Fee Schedule		130.95							Fee Schedule																				8913.24							Fee Schedule																																															
STRATTICE (LIFE CELL) MESH 1020002	278	RC	Q4130	CPT				Both			17062.5	7678.13	130.95	15356.25		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	12626.25							Fee Schedule		130.95							Fee Schedule																				15356.25							Fee Schedule																																															
STRATTICE (LIFE CELL) MESH 16200002	278	RC	C9356	CPT				Both			30643.2	13789.44	15.71	27578.88		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	22675.97							Fee Schedule																				16.89							Fee Schedule		27578.88							Fee Schedule		19.42							Fee Schedule		15.71							Fee Schedule											19.42							Fee Schedule		15.71							Fee Schedule		
STRATTICE 20X25 #2025002	278	RC	Q4130	CPT				Both			42610.05	19174.52	118.24	38349.05		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	31531.44							Fee Schedule		130.95							Fee Schedule											127.14							Fee Schedule		38349.05							Fee Schedule		146.21							Fee Schedule		118.24							Fee Schedule											146.21							Fee Schedule		118.24							Fee Schedule		
STRATTICE MESH 10X16  # 1016002	278	RC	Q4130	CPT				Both			13650	6142.5	118.24	12285		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	10101							Fee Schedule		130.95							Fee Schedule											127.14							Fee Schedule		12285							Fee Schedule		146.21							Fee Schedule		118.24							Fee Schedule											146.21							Fee Schedule		118.24							Fee Schedule		
"STREP PNEUMO AG, URN 16786"	302	RC	87899	CPT				Both			325	146.25	11.57	292.5	11.57							Fee Schedule		16.07							Fee Schedule		16.55							Fee Schedule		16.07							Fee Schedule											292.5							Fee Schedule																																															
STREPTOKINASE 250000	636	RC	J2995	CPT				Both			236.25	106.31	106.31	212.63		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	174.83							Fee Schedule																				127.14							Fee Schedule		212.63							Fee Schedule		146.21							Fee Schedule		118.24							Fee Schedule											146.21							Fee Schedule		118.24							Fee Schedule		
"STREPTOKINASE 750,000UNITS/VIAL"	636	RC	J2995	CPT				Both			1002.75	451.24	118.24	902.48		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	742.04							Fee Schedule																				127.14							Fee Schedule		902.48							Fee Schedule		146.21							Fee Schedule		118.24							Fee Schedule											146.21							Fee Schedule		118.24							Fee Schedule		
STREPTOMYCIN 1 GM INJ	636	RC	J3000	CPT				Both			50.4	22.68	1.29	45.36		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	37.3							Fee Schedule		27.69							Fee Schedule		1.29							Fee Schedule		16.07							Fee Schedule		45.36							Fee Schedule		18.48							Fee Schedule		14.95							Fee Schedule											18.48							Fee Schedule		14.95							Fee Schedule		
STRESSTABS 600 ZINC	250	RC	A9270	CPT				Both			1.58	0.71	0.01	1.42	0.01							Fee Schedule		1.17							Fee Schedule																													1.42							Fee Schedule																																															
STRETCH BAND 10 IN	271	RC						Both			7.35	3.31	3.31	6.62	4.78							Fee Schedule		5.44							Fee Schedule																													6.62							Fee Schedule																																															
STRETCH PANTIES NURSES CHOICE	271	RC						Both			6.3	2.84	2.84	30.92	4.1							Fee Schedule		4.66							Fee Schedule																				26.88							Fee Schedule		5.67							Fee Schedule		30.92							Fee Schedule		25							Fee Schedule											30.92							Fee Schedule		25							Fee Schedule		
STRKER UNIVERSAL HEAD # UH1-50-26	278	RC	C1776	CPT				Both			2362.5	1063.13	1063.13	2126.25		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1748.25							Fee Schedule																													2126.25							Fee Schedule																																															
STRONGYLOIDES AB IgG 34309   1ML SERUM	302	RC	86682	CPT				Both			113.4	51.03	11.56	102.06	11.56							Fee Schedule		14.45							Fee Schedule		13.4							Fee Schedule		13.01							Fee Schedule											102.06							Fee Schedule																				13.01							Fee Schedule																				
STRYK. 6.5 CANN. #3910075650	272	RC						Both			90.3	40.64	40.64	81.27	58.7							Fee Schedule		66.82							Fee Schedule																													81.27							Fee Schedule																																															
STRYK. 8.0 CANN. #3910075800	272	RC						Both			68.25	30.71	30.71	61.43	44.36							Fee Schedule		50.51							Fee Schedule																													61.43							Fee Schedule																																															
STRYK. 8.0 CANN. #3910-075-802	272	RC						Both			68.25	30.71	12.1	61.43	44.36							Fee Schedule		50.51							Fee Schedule																				13.01							Fee Schedule		61.43							Fee Schedule		14.96							Fee Schedule		12.1							Fee Schedule											14.96							Fee Schedule		12.1							Fee Schedule		
STRYK. 8.0 CANN. #3910-090-800	272	RC						Both			84	37.8	37.8	75.6	54.6							Fee Schedule		62.16							Fee Schedule																													75.6							Fee Schedule																																															
STRYK. COMPARTMENTAL PRESS. MONITOR C2DX	272	RC						Both			364.35	163.96	163.96	327.92	236.83							Fee Schedule		269.62							Fee Schedule																													327.92							Fee Schedule																																															
STRYK.INTRA-COMPARTMENTAL PRESS.TEST KIT	272	RC						Both			338.63	152.38	152.38	304.77	220.11							Fee Schedule		250.59							Fee Schedule																													304.77							Fee Schedule																																															
STRYKER  CYRAN CARTRIDGE 240-080-205	270	RC						Both			6.3	2.84	2.84	5.67	4.1							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
STRYKER  MIXING BOWL # 606-573	272	RC						Both			446.25	200.81	200.81	401.63	290.06							Fee Schedule		330.23							Fee Schedule																													401.63							Fee Schedule																																															
STRYKER 1.2MM OLIVE K-WIRE #XBR001002	278	RC	C1713	CPT				Both			392	176.4	176.4	352.8		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	290.08							Fee Schedule																													352.8							Fee Schedule																																															
STRYKER 1.4MM K-WIRE #45-80200	278	RC	C1713	CPT				Both			63	28.35	28.35	56.7		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	46.62							Fee Schedule																													56.7							Fee Schedule																																															
STRYKER 2.7MM LOCKING SCREW L12MM 656312	278	RC	C1713	CPT				Both			494	222.3	222.3	444.6		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	365.56							Fee Schedule																													444.6							Fee Schedule																																															
STRYKER 2.7MM LOCKING SCREW L16MM 656316	278	RC	C1713	CPT				Both			494	222.3	222.3	444.6		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	365.56							Fee Schedule																													444.6							Fee Schedule																																															
STRYKER 2.7MM LOCKING SCREW L18MM 656318	278	RC	C1713	CPT				Both			494	222.3	222.3	444.6		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	365.56							Fee Schedule																													444.6							Fee Schedule																																															
STRYKER 22MM CP SCREW #626922	278	RC	C1713	CPT				Both			714	321.3	321.3	642.6		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	528.36							Fee Schedule																													642.6							Fee Schedule																																															
STRYKER 2MM DRILL BIT #45-27010	272	RC						Both			339	152.55	152.55	305.1	220.35							Fee Schedule		250.86							Fee Schedule																													305.1							Fee Schedule																																															
STRYKER 3.5 CUTTER 0375-534-000	272	RC						Both			165.9	74.66	74.66	149.31	107.84							Fee Schedule		122.77							Fee Schedule																													149.31							Fee Schedule																																															
STRYKER 4.0 CUTTER 0375-544-000	272	RC						Both			935.55	421	421	842	608.11							Fee Schedule		692.31							Fee Schedule																													842							Fee Schedule																																															
STRYKER 4.0 MM BUR 0375-941-000	272	RC						Both			935.55	421	421	842	608.11							Fee Schedule		692.31							Fee Schedule																													842							Fee Schedule																																															
STRYKER 4.5 CUTTER 0380-544-150	272	RC						Both			935.55	421	421	842	608.11							Fee Schedule		692.31							Fee Schedule																													842							Fee Schedule																																															
STRYKER 5.5 CUTTER 0375-532-000	272	RC						Both			253.05	113.87	113.87	227.75	164.48							Fee Schedule		187.26							Fee Schedule																													227.75							Fee Schedule																																															
STRYKER 5.5 MM BUR 0375-951-000	272	RC						Both			438.9	197.51	197.51	395.01	285.29							Fee Schedule		324.79							Fee Schedule																													395.01							Fee Schedule																																															
STRYKER 6.5 CANN. 3910-075-650	272	RC						Both			84	37.8	37.8	75.6	54.6							Fee Schedule		62.16							Fee Schedule																													75.6							Fee Schedule																																															
STRYKER AARDVARK # 0279-251-101	272	RC						Both			403.2	181.44	181.44	362.88	262.08							Fee Schedule		298.37							Fee Schedule																													362.88							Fee Schedule																																															
STRYKER ACCOLADE DIST SPACER #1059-4515	278	RC	C1776	CPT				Both			472.5	212.63	212.63	425.25		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	349.65							Fee Schedule																													425.25							Fee Schedule																																															
STRYKER ACCULADE 6057-0230D	278	RC	C1776	CPT				Both			11025	4961.25	4961.25	9922.5		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	8158.5							Fee Schedule																													9922.5							Fee Schedule																																															
STRYKER ACCULADE 6057-0335D	278	RC	C1776	CPT				Both			11025	4961.25	4961.25	9922.5		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	8158.5							Fee Schedule																													9922.5							Fee Schedule																																															
STRYKER ACCULADE 6057-0435D	278	RC	C1776	CPT				Both			11025	4961.25	4961.25	9922.5		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	8158.5							Fee Schedule																													9922.5							Fee Schedule																																															
STRYKER ACCULADE 6057-0537D	278	RC	C1776	CPT				Both			11025	4961.25	4961.25	9922.5		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	8158.5							Fee Schedule																													9922.5							Fee Schedule																																															
STRYKER ACCULADE 6057-0637D	278	RC	C1776	CPT				Both			11025	4961.25	4961.25	9922.5		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	8158.5							Fee Schedule																													9922.5							Fee Schedule																																															
STRYKER ACCULADE 6057-0740D	278	RC	C1776	CPT				Both			11025	4961.25	4961.25	9922.5		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	8158.5							Fee Schedule																													9922.5							Fee Schedule																																															
STRYKER ACCULADE 6058-0230D	278	RC	C1776	CPT				Both			11025	4961.25	4961.25	9922.5		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	8158.5							Fee Schedule																													9922.5							Fee Schedule																																															
STRYKER ACCULADE 6058-0335D	278	RC	C1776	CPT				Both			11025	4961.25	4961.25	9922.5		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	8158.5							Fee Schedule																													9922.5							Fee Schedule																																															
STRYKER ACCULADE 6058-0435D	278	RC	C1776	CPT				Both			11025	4961.25	4961.25	9922.5		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	8158.5							Fee Schedule																													9922.5							Fee Schedule																																															
STRYKER ACCULADE 6058-0537D	278	RC	C1776	CPT				Both			11025	4961.25	4961.25	9922.5		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	8158.5							Fee Schedule																													9922.5							Fee Schedule																																															
STRYKER ACCULADE 6058-0637D	278	RC	C1776	CPT				Both			11025	4961.25	4961.25	9922.5		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	8158.5							Fee Schedule																													9922.5							Fee Schedule																																															
STRYKER ACCULADE 6058-0740D	278	RC	C1776	CPT				Both			11025	4961.25	4961.25	9922.5		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	8158.5							Fee Schedule																													9922.5							Fee Schedule																																															
STRYKER ACCULADE DISTAL SPACER 1059-2310	278	RC	C1776	CPT				Both			472.5	212.63	212.63	425.25		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	349.65							Fee Schedule																													425.25							Fee Schedule																																															
STRYKER ACCULADE DISTAL SPACER 1059-2311	278	RC	C1776	CPT				Both			472.5	212.63	212.63	425.25		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	349.65							Fee Schedule																													425.25							Fee Schedule																																															
STRYKER ACCULADE DISTAL SPACER 1059-2312	278	RC	C1776	CPT				Both			472.5	212.63	212.63	425.25		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	349.65							Fee Schedule																													425.25							Fee Schedule																																															
STRYKER ACCULADE DISTAL SPACER 1059-2313	278	RC	C1776	CPT				Both			472.5	212.63	212.63	425.25		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	349.65							Fee Schedule																													425.25							Fee Schedule																																															
STRYKER ACCULADE DISTAL SPACER 1059-2314	278	RC	C1776	CPT				Both			472.5	212.63	212.63	425.25		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	349.65							Fee Schedule																													425.25							Fee Schedule																																															
STRYKER ACCULADE DISTAL SPACER 1059-2315	278	RC	C1776	CPT				Both			472.5	212.63	212.63	425.25		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	349.65							Fee Schedule																													425.25							Fee Schedule																																															
STRYKER ACCULADE DISTAL SPACER 1059-4512	278	RC	C1776	CPT				Both			468.3	210.74	210.74	421.47		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	346.54							Fee Schedule																													421.47							Fee Schedule																																															
STRYKER ACCULADE DISTAL SPACER 1059-4513	278	RC	C1776	CPT				Both			472.5	212.63	212.63	425.25		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	349.65							Fee Schedule																													425.25							Fee Schedule																																															
STRYKER ACCULADE DISTAL SPACER 1059-4514	278	RC	C1776	CPT				Both			472.5	212.63	212.63	425.25		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	349.65							Fee Schedule																													425.25							Fee Schedule																																															
STRYKER ACCULADE DISTAL SPACER 1059-4515	278	RC	C1776	CPT				Both			472.5	212.63	212.63	425.25		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	349.65							Fee Schedule																													425.25							Fee Schedule																																															
STRYKER ACCULADE DISTAL SPACER 1059-4516	278	RC	C1776	CPT				Both			472.5	212.63	212.63	425.25		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	349.65							Fee Schedule																													425.25							Fee Schedule																																															
STRYKER ACCULADE DISTAL SPACER 1059-4517	278	RC	C1776	CPT				Both			472.5	212.63	212.63	425.25		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	349.65							Fee Schedule																													425.25							Fee Schedule																																															
STRYKER ACCULADE DISTAL SPACER 1059-6713	278	RC	C1776	CPT				Both			472.5	212.63	212.63	425.25		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	349.65							Fee Schedule																													425.25							Fee Schedule																																															
STRYKER ACCULADE DISTAL SPACER 1059-6714	278	RC	C1776	CPT				Both			472.5	212.63	212.63	425.25		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	349.65							Fee Schedule																													425.25							Fee Schedule																																															
STRYKER ACCULADE DISTAL SPACER 1059-6715	278	RC	C1776	CPT				Both			472.5	212.63	212.63	425.25		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	349.65							Fee Schedule																													425.25							Fee Schedule																																															
STRYKER ACCULADE DISTAL SPACER 1059-6716	278	RC	C1776	CPT				Both			472.5	212.63	212.63	425.25		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	349.65							Fee Schedule																													425.25							Fee Schedule																																															
STRYKER ACCULADE DISTAL SPACER 1059-6717	278	RC	C1776	CPT				Both			472.5	212.63	212.63	425.25		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	349.65							Fee Schedule																													425.25							Fee Schedule																																															
STRYKER ACCULADE DISTAL SPACER 1059-6718	278	RC	C1776	CPT				Both			472.5	212.63	212.63	425.25		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	349.65							Fee Schedule																													425.25							Fee Schedule																																															
STRYKER ACL PACK 234-020-280	272	RC						Both			1490	670.5	670.5	1341	968.5							Fee Schedule		1102.6							Fee Schedule																													1341							Fee Schedule																																															
STRYKER ACL SCREW 234-010-061	278	RC	C1713	CPT				Both			613.2	275.94	275.94	551.88		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	453.77							Fee Schedule																													551.88							Fee Schedule																																															
STRYKER ACL SCREW 234-010-062	278	RC	C1713	CPT				Both			614.25	276.41	276.41	552.83		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	454.55							Fee Schedule																													552.83							Fee Schedule																																															
STRYKER ACL SCREW 234-010-063	278	RC	C1713	CPT				Both			519.75	233.89	233.89	467.78		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	384.62							Fee Schedule																													467.78							Fee Schedule																																															
STRYKER ACL SCREW 234-010-064	278	RC	C1713	CPT				Both			613.2	275.94	275.94	551.88		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	453.77							Fee Schedule																													551.88							Fee Schedule																																															
STRYKER ACL SCREW 234-010-065	278	RC	C1713	CPT				Both			614.25	276.41	276.41	552.83		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	454.55							Fee Schedule																													552.83							Fee Schedule																																															
STRYKER ACL SCREW 234-010-066	278	RC	C1713	CPT				Both			519.75	233.89	233.89	467.78		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	384.62							Fee Schedule																													467.78							Fee Schedule																																															
STRYKER ACL SCREW 234-010-067	278	RC	C1713	CPT				Both			614.25	276.41	276.41	552.83		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	454.55							Fee Schedule																													552.83							Fee Schedule																																															
STRYKER ACL SCREW 234-101-020	278	RC	C1713	CPT				Both			1207.5	543.38	543.38	1086.75		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	893.55							Fee Schedule																													1086.75							Fee Schedule																																															
STRYKER ADM/MDM INSERT 1236-2-848	278	RC	C1776	CPT				Both			3307.5	1488.38	1488.38	2976.75		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	2447.55							Fee Schedule																													2976.75							Fee Schedule																																															
STRYKER ADVANCE MIXING CEMENT 0306-573	272	RC						Both			294	132.3	132.3	264.6	191.1							Fee Schedule		217.56							Fee Schedule																													264.6							Fee Schedule																																															
STRYKER AGGRESIVE + # 375-544-000	272	RC						Both			226.8	102.06	102.06	204.12	147.42							Fee Schedule		167.83							Fee Schedule																													204.12							Fee Schedule																																															
STRYKER AIR MENISCAL REPAIR DEVICE 4720	278	RC	C1713	CPT				Both			1963.5	883.58	883.58	1767.15		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1452.99							Fee Schedule																													1767.15							Fee Schedule																																															
STRYKER ASYM. PATELLA # 5551-L-350	278	RC	C1776	CPT				Both			1575	708.75	708.75	1417.5		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1165.5							Fee Schedule																													1417.5							Fee Schedule																																															
STRYKER ASYM. PATELLA # 5551-L-381	278	RC	C1776	CPT				Both			1323	595.35	595.35	1190.7		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	979.02							Fee Schedule																													1190.7							Fee Schedule																																															
STRYKER ASYMMETRIC PATELLA  5551-L-401	278	RC	C1776	CPT				Both			1323	595.35	595.35	1190.7		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	979.02							Fee Schedule																													1190.7							Fee Schedule																																															
STRYKER ASYMMETRIC PATELLA 5551-L-320	278	RC	C1776	CPT				Both			1323	595.35	595.35	1190.7		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	979.02							Fee Schedule																													1190.7							Fee Schedule																																															
STRYKER BALL TIPPED GUIDE ROD 702336S	272	RC						Both			510.3	229.64	229.64	459.27	331.7							Fee Schedule		377.62							Fee Schedule																													459.27							Fee Schedule																																															
STRYKER BEADED CABLE&SLEEVE 6704-0-520	278	RC	C1713	CPT				Both			1312.5	590.63	590.63	1181.25		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	971.25							Fee Schedule																													1181.25							Fee Schedule																																															
STRYKER BIO-ZIP 3910-200-025	278	RC	C1713	CPT				Both			821.1	369.5	369.5	738.99		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	607.61							Fee Schedule																													738.99							Fee Schedule																																															
STRYKER BIPOLAR HEAD # UH1-43-26	278	RC	C1776	CPT				Both			2362.5	1063.13	1063.13	2126.25		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1748.25							Fee Schedule																													2126.25							Fee Schedule																																															
STRYKER BIPOLAR HEAD # UH1-44-26	278	RC	C1776	CPT				Both			2362.5	1063.13	1063.13	2126.25		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1748.25							Fee Schedule																													2126.25							Fee Schedule																																															
STRYKER BIPOLAR HEAD # UH1-45-26	278	RC	C1776	CPT				Both			2362.5	1063.13	1063.13	2126.25		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1748.25							Fee Schedule																													2126.25							Fee Schedule																																															
STRYKER BLACK CARTRIDGE 240-080-202	270	RC						Both			6.3	2.84	2.84	5.67	4.1							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
STRYKER CANC. BONE SCREW 6.5 2030-6530-1	278	RC	C1713	CPT				Both			263.03	118.36	118.36	236.73		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	194.64							Fee Schedule																													236.73							Fee Schedule																																															
STRYKER CAP SCREW 3370-1-060	278	RC	C1713	CPT				Both			453.6	204.12	204.12	408.24		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	335.66							Fee Schedule																													408.24							Fee Schedule																																															
STRYKER CEMENT RESTICTOR #B000-0300	278	RC	C1776	CPT				Both			525	236.25	236.25	472.5		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	388.5							Fee Schedule																													472.5							Fee Schedule																																															
STRYKER CEMENT RESTRIC.#B000-0240	278	RC	C1776	CPT				Both			525	236.25	236.25	472.5		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	388.5							Fee Schedule																													472.5							Fee Schedule																																															
STRYKER CEMENT RESTRIC.#B000-1185	278	RC	C1776	CPT				Both			551.57	248.21	248.21	496.41		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	408.16							Fee Schedule																													496.41							Fee Schedule																																															
STRYKER CEMENT RESTRIC.#B000-1240	278	RC	C1776	CPT				Both			551.57	248.21	248.21	496.41		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	408.16							Fee Schedule																													496.41							Fee Schedule																																															
STRYKER CEMENTED STEM 5560-S-112	278	RC	C1776	CPT				Both			3155.25	1419.86	1419.86	2839.73		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	2334.89							Fee Schedule																													2839.73							Fee Schedule																																															
STRYKER CEMENTLESS LINER 626-00-42E	278	RC	C1776	CPT				Both			3528	1587.6	1587.6	3175.2		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	2610.72							Fee Schedule																													3175.2							Fee Schedule																																															
STRYKER CRUCIATE FEMORAL 5510-F-301	278	RC	C1776	CPT				Both			5827.5	2622.38	2622.38	5244.75		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	4312.35							Fee Schedule																													5244.75							Fee Schedule																																															
STRYKER CUTOFF WHEEL 5120130250	272	RC						Both			39.9	17.96	17.96	35.91	25.94							Fee Schedule		29.53							Fee Schedule																													35.91							Fee Schedule																																															
STRYKER CUTOFF WHEEL 5400005000	272	RC						Both			69.46	31.26	31.26	62.51	45.15							Fee Schedule		51.4							Fee Schedule																													62.51							Fee Schedule																																															
STRYKER CUTOFF WHEEL 5400006000	272	RC						Both			39.9	17.96	17.96	35.91	25.94							Fee Schedule		29.53							Fee Schedule																													35.91							Fee Schedule																																															
STRYKER DIST. STEM CENT. # 6259-8-140	278	RC	C1776	CPT				Both			510.3	229.64	229.64	459.27		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	377.62							Fee Schedule																													459.27							Fee Schedule																																															
STRYKER DIST. STEM CENT. #6259-8-160	278	RC	C1762	CPT				Both			483	217.35	217.35	434.7		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	357.42							Fee Schedule																													434.7							Fee Schedule																																															
STRYKER DIST. STEM CENTR. # 6259-8-120	278	RC	C1776	CPT				Both			510.3	229.64	229.64	459.27		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	377.62							Fee Schedule																													459.27							Fee Schedule																																															
STRYKER DIST. STEM CENTR. # 6259-8-130	278	RC	C1776	CPT				Both			510.3	229.64	229.64	459.27		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	377.62							Fee Schedule																													459.27							Fee Schedule																																															
STRYKER DRILL COVER  7222-130-000	272	RC						Both			711.18	320.03	320.03	640.06	462.27							Fee Schedule		526.27							Fee Schedule																													640.06							Fee Schedule																																															
STRYKER EGG BUR  #1607-2-35	272	RC						Both			292.95	131.83	131.83	263.66	190.42							Fee Schedule		216.78							Fee Schedule																													263.66							Fee Schedule																																															
STRYKER ENDOHEAD # 6942-5-042	278	RC	C1776	CPT				Both			2362.5	1063.13	1063.13	2126.25		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1748.25							Fee Schedule																													2126.25							Fee Schedule																																															
STRYKER ENERGY ABLATOR # 279-351-100	272	RC						Both			403.2	181.44	181.44	362.88	262.08							Fee Schedule		298.37							Fee Schedule																													362.88							Fee Schedule																																															
STRYKER ESOPHAGEAL KIT INFRAVISION	272	RC						Both			783.3	352.49	352.49	704.97	509.15							Fee Schedule		579.64							Fee Schedule																													704.97							Fee Schedule																																															
STRYKER FAST CUTTING BURR #1608-6-139	272	RC						Both			185.85	83.63	83.63	167.27	120.8							Fee Schedule		137.53							Fee Schedule																													167.27							Fee Schedule																																															
STRYKER FAST CUTTING BURR #1608-6-139	272	RC						Both			170.1	76.55	76.55	153.09	110.57							Fee Schedule		125.87							Fee Schedule																													153.09							Fee Schedule																																															
STRYKER FAST CUTTING BURR #1608-6-145	272	RC						Both			170.1	76.55	76.55	153.09	110.57							Fee Schedule		125.87							Fee Schedule																													153.09							Fee Schedule																																															
STRYKER FAST CUTTING BURR #1608-6-149	272	RC						Both			170.1	76.55	76.55	153.09	110.57							Fee Schedule		125.87							Fee Schedule																													153.09							Fee Schedule																																															
STRYKER FEM. HEAD STAND. # 6260-9-126	278	RC	C1776	CPT				Both			2047.5	921.38	921.38	1842.75		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1515.15							Fee Schedule																													1842.75							Fee Schedule																																															
STRYKER FEM. HEAD STAND. # 6260-9-226	278	RC	C1776	CPT				Both			2047.5	921.38	921.38	1842.75		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1515.15							Fee Schedule																													1842.75							Fee Schedule																																															
STRYKER FEM. HEAD STAND. # 6260-9-326	278	RC	C1776	CPT				Both			3068.1	1380.65	1380.65	2761.29		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	2270.39							Fee Schedule																													2761.29							Fee Schedule																																															
STRYKER FEM. HEAD STAND. # 6942-5-052	278	RC	C1776	CPT				Both			2362.5	1063.13	1063.13	2126.25		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1748.25							Fee Schedule																													2126.25							Fee Schedule																																															
STRYKER FEM. POSTERIOR  5515-F-602	278	RC	C1713	CPT				Both			5827.5	2622.38	2622.38	5244.75		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	4312.35							Fee Schedule																													5244.75							Fee Schedule																																															
STRYKER FLEX DRILL PIN 234-108-200	272	RC						Both			1106.18	497.78	497.78	995.56	719.02							Fee Schedule		818.57							Fee Schedule																													995.56							Fee Schedule																																															
STRYKER FLOSTEADY 035-800-006	272	RC						Both			170.1	76.55	76.55	153.09	110.57							Fee Schedule		125.87							Fee Schedule																													153.09							Fee Schedule																																															
STRYKER FLUTE BARRELL BURR# 375-941-000	272	RC						Both			226.8	102.06	102.06	204.12	147.42							Fee Schedule		167.83							Fee Schedule																													204.12							Fee Schedule																																															
STRYKER FLUTED PIN # 7650-2038A	278	RC	C1776	CPT				Both			1113	500.85	500.85	1001.7		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	823.62							Fee Schedule																													1001.7							Fee Schedule																																															
STRYKER FORCE FIBER #3910-405-638	272	RC						Both			231	103.95	103.95	207.9	150.15							Fee Schedule		170.94							Fee Schedule																													207.9							Fee Schedule																																															
STRYKER FORCE FIBER 3910-200-021	272	RC						Both			50.4	22.68	22.68	45.36	32.76							Fee Schedule		37.3							Fee Schedule																													45.36							Fee Schedule																																															
STRYKER FORCE FIBER 3910-200-025	272	RC						Both			578.55	260.35	260.35	520.7	376.06							Fee Schedule		428.13							Fee Schedule																													520.7							Fee Schedule																																															
STRYKER FORCE FIBER 3910-900-020  ENDO	272	RC						Both			90	40.5	40.5	81	58.5							Fee Schedule		66.6							Fee Schedule																													81							Fee Schedule																																															
STRYKER FORCE FIBER 3910-900-021   ENDO	272	RC						Both			90	40.5	40.5	81	58.5							Fee Schedule		66.6							Fee Schedule																													81							Fee Schedule																																															
STRYKER FORCE FIBER 3910-900-050	272	RC						Both			143.85	64.73	64.73	129.47	93.5							Fee Schedule		106.45							Fee Schedule																													129.47							Fee Schedule																																															
STRYKER GUIDE WIRE 234-108-020   ENDO	272	RC						Both			956	430.2	430.2	860.4	621.4							Fee Schedule		707.44							Fee Schedule																													860.4							Fee Schedule																																															
STRYKER HEAD COMPONENT # 6942-5-041	278	RC	C1776	CPT				Both			2362.5	1063.13	1063.13	2126.25		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1748.25							Fee Schedule																													2126.25							Fee Schedule																																															
STRYKER HEAD COMPONENT # 6942-5-044	278	RC	C1776	CPT				Both			2362.5	1063.13	1063.13	2126.25		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1748.25							Fee Schedule																													2126.25							Fee Schedule																																															
STRYKER HEAD COMPONENT # 6942-5-056	278	RC	C1776	CPT				Both			2362.5	1063.13	1063.13	2126.25		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1748.25							Fee Schedule																													2126.25							Fee Schedule																																															
STRYKER HEAD COMPONENT #6942-5-055	278	RC	C1776	CPT				Both			2362.5	1063.13	1063.13	2126.25		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1748.25							Fee Schedule																													2126.25							Fee Schedule																																															
STRYKER HEAD COMPONENT #6942-5-058	278	RC	C1776	CPT				Both			2362.5	1063.13	1063.13	2126.25		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1748.25							Fee Schedule																													2126.25							Fee Schedule																																															
STRYKER HEAD COMPONENT 6942-5-045	278	RC	C1776	CPT				Both			2362.5	1063.13	1063.13	2126.25		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1748.25							Fee Schedule																													2126.25							Fee Schedule																																															
STRYKER HEAD COMPONENT 6942-5-047	278	RC	C1776	CPT				Both			2362.5	1063.13	1063.13	2126.25		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1748.25							Fee Schedule																													2126.25							Fee Schedule																																															
STRYKER HEAD COMPONENT 6942-5-048	278	RC	C1776	CPT				Both			2362.5	1063.13	1063.13	2126.25		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1748.25							Fee Schedule																													2126.25							Fee Schedule																																															
STRYKER HEAD COMPONENT 6942-5-049	278	RC	C1776	CPT				Both			2362.5	1063.13	1063.13	2126.25		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1748.25							Fee Schedule																													2126.25							Fee Schedule																																															
STRYKER HEAD COMPONENT 6942-5-050	278	RC	C1776	CPT				Both			2362.5	1063.13	1063.13	2126.25		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1748.25							Fee Schedule																													2126.25							Fee Schedule																																															
STRYKER HEAD COMPONENT 6942-5-051	278	RC	C1776	CPT				Both			2362.5	1063.13	1063.13	2126.25		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1748.25							Fee Schedule																													2126.25							Fee Schedule																																															
STRYKER HEAD COMPONENT 6942-5-053	278	RC	C1776	CPT				Both			2362.5	1063.13	1063.13	2126.25		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1748.25							Fee Schedule																													2126.25							Fee Schedule																																															
STRYKER HEAD COMPONENT 6942-5-054	278	RC	C1776	CPT				Both			2362.5	1063.13	1063.13	2126.25		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1748.25							Fee Schedule																													2126.25							Fee Schedule																																															
STRYKER HEAD PROSTHESIS #6948-0-508	278	RC	C1776	CPT				Both			7218.75	3248.44	3248.44	6496.88		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	5341.88							Fee Schedule																													6496.88							Fee Schedule																																															
STRYKER HIP STEM # 6265-3-114	278	RC	C1776	CPT				Both			3937.5	1771.88	1771.88	3543.75		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	2913.75							Fee Schedule																													3543.75							Fee Schedule																																															
STRYKER HYDRO SET # 397015	278	RC	C9359	CPT				Both			13650	6142.5	6142.5	12285		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	10101							Fee Schedule																													12285							Fee Schedule																																															
STRYKER ICONIX ANCHOR 3910-500-322	278	RC	C1713	CPT				Both			1386	623.7	623.7	1247.4		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1025.64							Fee Schedule																													1247.4							Fee Schedule																																															
STRYKER ICONIX ANCHOR 3910-500-512	272	RC	C1713	CPT				Both			1386	623.7	306.41	1247.4	306.41							Fee Schedule		1025.64							Fee Schedule																													1247.4							Fee Schedule																																															
STRYKER ICONIX ANCHOR 3910-500-522	278	RC	C1713	CPT				Both			1386	623.7	623.7	1247.4		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1025.64							Fee Schedule																													1247.4							Fee Schedule																																															
STRYKER ICONIX ANCHOR 3910-500-532	278	RC	C1713	CPT				Both			1212.75	545.74	545.74	1091.48		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	897.44							Fee Schedule																													1091.48							Fee Schedule																																															
STRYKER ICONIX ANCHOR 3910-500-920	278	RC	C1713	CPT				Both			493.5	222.08	222.08	444.15		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	365.19							Fee Schedule																													444.15							Fee Schedule																																															
STRYKER ICONIX ANCHOR 3910-500-921	278	RC	C1713	CPT				Both			1201.2	540.54	540.54	1081.08		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	888.89							Fee Schedule																													1081.08							Fee Schedule																																															
STRYKER ICONIX ANCHOR 3910-500-922	278	RC	C1713	CPT				Both			1201.2	540.54	540.54	1081.08		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	888.89							Fee Schedule																													1081.08							Fee Schedule																																															
STRYKER ICONIX ANCHOR 3910-500-931	278	RC	C1713	CPT				Both			1201.2	540.54	540.54	1081.08		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	888.89							Fee Schedule																													1081.08							Fee Schedule																																															
STRYKER ICONIX DRILL 3910-500-568	272	RC						Both			708.75	318.94	318.94	637.88	460.69							Fee Schedule		524.48							Fee Schedule																													637.88							Fee Schedule																																															
STRYKER ICONIX DRILL 3910-500-569	272	RC						Both			708.75	318.94	318.94	637.88	460.69							Fee Schedule		524.48							Fee Schedule																													637.88							Fee Schedule																																															
STRYKER IRIS URETERAL STENT 0220180518	272	RC	C2617	CPT				Both			863	388.35	189.57	776.7	189.57							Fee Schedule		638.62							Fee Schedule																													776.7							Fee Schedule																																															
STRYKER KIRSCHNER WIRE 1210-6450S	272	RC						Both			340.2	153.09	153.09	306.18	221.13							Fee Schedule		251.75							Fee Schedule																													306.18							Fee Schedule																																															
STRYKER KNOTLESS ANCHOR 3910-600-062	278	RC	C1713	CPT				Both			1347.15	606.22	606.22	1212.44		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	996.89							Fee Schedule																													1212.44							Fee Schedule																																															
STRYKER LONG NARROW BLADE #2296-003-111	272	RC						Both			102	45.9	45.9	91.8	66.3							Fee Schedule		75.48							Fee Schedule																													91.8							Fee Schedule																																															
STRYKER LONG NARROW BLADE #2296-003-414	272	RC						Both			104	46.8	46.8	93.6	67.6							Fee Schedule		76.96							Fee Schedule																													93.6							Fee Schedule																																															
STRYKER LT CYAN CARTRIDGE 240-080-204	270	RC						Both			6.3	2.84	2.84	5.67	4.1							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
STRYKER LT MEGENTA CARTRIDGE 240-080-206	270	RC						Both			6.3	2.84	2.84	5.67	4.1							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
STRYKER MAGENTA CARTRIDGE 240-080-207	270	RC						Both			6.3	2.84	2.84	5.67	4.1							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
STRYKER MICRODEB.BLADE 4.0 290-540-000	272	RC						Both			326.55	146.95	146.95	293.9	212.26							Fee Schedule		241.65							Fee Schedule																													293.9							Fee Schedule																																															
STRYKER MIXING BOWL/ SPAT 6201-3-410	272	RC						Both			39.9	17.96	17.96	35.91	25.94							Fee Schedule		29.53							Fee Schedule																													35.91							Fee Schedule																																															
STRYKER MTP CP PLATE (R) #626892	278	RC	C1713	CPT				Both			7169	3226.05	3226.05	6452.1		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	5305.06							Fee Schedule																													6452.1							Fee Schedule																																															
STRYKER NECK ADJ. SLEEVE 6942-6-075	278	RC	C1776	CPT				Both			647.85	291.53	291.53	583.07		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	479.41							Fee Schedule																													583.07							Fee Schedule																																															
STRYKER NECK ADJ. SLEEVE 6942-6-080	278	RC	C1776	CPT				Both			647.85	291.53	291.53	583.07		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	479.41							Fee Schedule																													583.07							Fee Schedule																																															
STRYKER NECK ANGLE HIP STEM 6720-0330	278	RC	C1776	CPT				Both			9135	4110.75	4110.75	8221.5		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	6759.9							Fee Schedule																													8221.5							Fee Schedule																																															
STRYKER NECK ANGLE HIP STEM 6720-0435	278	RC	C1776	CPT				Both			11025	4961.25	4961.25	9922.5		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	8158.5							Fee Schedule																													9922.5							Fee Schedule																																															
STRYKER ORTHO TIB. BEARING 5531-P-313	278	RC	C1776	CPT				Both			3150	1417.5	1417.5	2835		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	2331							Fee Schedule																													2835							Fee Schedule																																															
STRYKER ORTHO. ACETAB. SHELL 502-11-48D	278	RC	C1776	CPT				Both			3307.5	1488.38	1488.38	2976.75		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	2447.55							Fee Schedule																													2976.75							Fee Schedule																																															
STRYKER ORTHO. ACETAB. SHELL 542-11-50E	278	RC	C1776	CPT				Both			3150	1417.5	1417.5	2835		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	2331							Fee Schedule																													2835							Fee Schedule																																															
STRYKER ORTHO. DRILL BIT #1320-3042S	272	RC						Both			510.3	229.64	229.64	459.27	331.7							Fee Schedule		377.62							Fee Schedule																													459.27							Fee Schedule																																															
STRYKER ORTHO. TROC NAIL #3125-1180S	278	RC	C1776	CPT				Both			3855.6	1735.02	1735.02	3470.04		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	2853.14							Fee Schedule																													3470.04							Fee Schedule																																															
STRYKER ORTHO. V40 FEM. HEAD 6570-0-128	278	RC	C1776	CPT				Both			3937.5	1771.88	1771.88	3543.75		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	2913.75							Fee Schedule																													3543.75							Fee Schedule																																															
STRYKER ORTHO. V40 FEM. HEAD 6570-0-328	278	RC	C1776	CPT				Both			3150	1417.5	1417.5	2835		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	2331							Fee Schedule																													2835							Fee Schedule																																															
STRYKER ORTHO. V40 FEM. HEAD 6570-0-436	278	RC	C1776	CPT				Both			3937.5	1771.88	1771.88	3543.75		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	2913.75							Fee Schedule																													3543.75							Fee Schedule																																															
STRYKER ORTHO.ADJ.SLEEVE #6942-6-065	278	RC	C1776	CPT				Both			651	292.95	292.95	585.9		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	481.74							Fee Schedule																													585.9							Fee Schedule																																															
STRYKER ORTHO.ADJ.SLEEVE #6942-6-070	278	RC	C1776	CPT				Both			645.75	290.59	290.59	581.18		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	477.86							Fee Schedule																													581.18							Fee Schedule																																															
STRYKER ORTHO.CEMENT RESTRICT B000-0185	278	RC	C1776	CPT				Both			525	236.25	236.25	472.5		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	388.5							Fee Schedule																													472.5							Fee Schedule																																															
STRYKER ORTHO.ENDO HEAD #6942-5-043	278	RC	C1776	CPT				Both			2362.5	1063.13	1063.13	2126.25		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1748.25							Fee Schedule																													2126.25							Fee Schedule																																															
STRYKER ORTHO.GUIDE WIRE #1806-0085S	272	RC						Both			623.7	280.67	280.67	561.33	405.41							Fee Schedule		461.54							Fee Schedule																													561.33							Fee Schedule																																															
STRYKER ORTHO.HEAD COMPONENT 6942-5-046	278	RC	C1776	CPT				Both			2362.5	1063.13	1063.13	2126.25		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1748.25							Fee Schedule																													2126.25							Fee Schedule																																															
STRYKER ORTHO.HIP STEM #6070-0730A	278	RC	C1776	CPT				Both			5953.5	2679.08	2679.08	5358.15		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	4405.59							Fee Schedule																													5358.15							Fee Schedule																																															
STRYKER ORTHO.HIP STEM 6265-3-100	278	RC	C1776	CPT				Both			12016.2	5407.29	5407.29	10814.58		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	8891.99							Fee Schedule																													10814.58							Fee Schedule																																															
STRYKER ORTHO.HIP STEM 6265-3-111	278	RC	C1776	CPT				Both			5868.45	2640.8	2640.8	5281.61		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	4342.65							Fee Schedule																													5281.61							Fee Schedule																																															
STRYKER ORTHO.HIP STEM 6265-3-112	278	RC	C1776	CPT				Both			5868.45	2640.8	2640.8	5281.61		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	4342.65							Fee Schedule																													5281.61							Fee Schedule																																															
STRYKER ORTHO.HIP STEM 6265-3-113	278	RC	C1776	CPT				Both			5265.75	2369.59	2369.59	4739.18		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	3896.66							Fee Schedule																													4739.18							Fee Schedule																																															
STRYKER ORTHO.LOCK SCREW #1896-5042S	278	RC	C1776	CPT				Both			623.7	280.67	280.67	561.33		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	461.54							Fee Schedule																													561.33							Fee Schedule																																															
STRYKER ORTHO.SET SCREW #3003-08228	278	RC	C1776	CPT				Both			510.3	229.64	229.64	459.27		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	377.62							Fee Schedule																													459.27							Fee Schedule																																															
STRYKER ORTHO.STEM 6259-8-100	278	RC	C1776	CPT				Both			510.3	229.64	229.64	459.27		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	377.62							Fee Schedule																													459.27							Fee Schedule																																															
STRYKER ORTHO.STEM 6259-8-110	278	RC	C1776	CPT				Both			481.95	216.88	216.88	433.76		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	356.64							Fee Schedule																													433.76							Fee Schedule																																															
STRYKER ORTHO.STEM 6259-8-150	278	RC	C1776	CPT				Both			510.3	229.64	229.64	459.27		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	377.62							Fee Schedule																													459.27							Fee Schedule																																															
STRYKER PEEK ANCHOR 3910-500-391	278	RC	C1713	CPT				Both			2819.25	1268.66	1268.66	2537.33		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	2086.25							Fee Schedule																													2537.33							Fee Schedule																																															
STRYKER PEEK ZIP ANCHOR 3910-200-035	278	RC	C1713	CPT				Both			710.85	319.88	319.88	639.77		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	526.03							Fee Schedule																													639.77							Fee Schedule																																															
STRYKER PEEK ZIP ANCHOR 3910-200-075	278	RC	C1713	CPT				Both			835	375.75	375.75	751.5		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	617.9							Fee Schedule																													751.5							Fee Schedule																																															
STRYKER PLUMO-AWAY #620-030-600	272	RC						Both			68.25	30.71	30.71	61.43	44.36							Fee Schedule		50.51							Fee Schedule																													61.43							Fee Schedule																																															
STRYKER POLYETHYLENE INSERT 623-00-36D	278	RC	C1776	CPT				Both			3937.5	1771.88	1771.88	3543.75		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	2913.75							Fee Schedule																													3543.75							Fee Schedule																																															
STRYKER PRINTER PAPER  240-080-231	270	RC						Both			10.76	4.84	4.84	9.68	6.99							Fee Schedule		7.96							Fee Schedule																													9.68							Fee Schedule																																															
STRYKER PRP REGEN KIT 8495-9-001	272	RC						Both			1050.89	472.9	472.9	945.8	683.08							Fee Schedule		777.66							Fee Schedule																													945.8							Fee Schedule																																															
STRYKER RADIAL HEAD  6948-0-511	278	RC	C1776	CPT				Both			7218.75	3248.44	3248.44	6496.88		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	5341.88							Fee Schedule																													6496.88							Fee Schedule																																															
STRYKER RADIAL HEAD  6948-5-511	278	RC	C1776	CPT				Both			7218.75	3248.44	3248.44	6496.88		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	5341.88							Fee Schedule																													6496.88							Fee Schedule																																															
STRYKER RADIAL HEAD PROSTH 6948 0 612	278	RC	C1776	CPT				Both			6720	3024	3024	6048		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	4972.8							Fee Schedule																													6048							Fee Schedule																																															
STRYKER REAMER #705172	272	RC						Both			1944	874.8	874.8	1749.6	1263.6							Fee Schedule		1438.56							Fee Schedule																													1749.6							Fee Schedule																																															
STRYKER RELEX ANCHOR # 3910-600-060	278	RC	C1713	CPT				Both			1575	708.75	708.75	1417.5		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1165.5							Fee Schedule																													1417.5							Fee Schedule																																															
STRYKER RESECTOR CUTTER# 0375-562-000	272	RC						Both			220.5	99.23	99.23	198.45	143.33							Fee Schedule		163.17							Fee Schedule																													198.45							Fee Schedule																																															
STRYKER RESECTOR CUTTER# 375-534-000	272	RC						Both			226.8	102.06	102.06	204.12	147.42							Fee Schedule		167.83							Fee Schedule																													204.12							Fee Schedule																																															
STRYKER REST. MOD. HIP SYSTEM 6276-1-023	278	RC	C1776	CPT				Both			16292.85	7331.78	7331.78	14663.57		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	12056.71							Fee Schedule																													14663.57							Fee Schedule																																															
STRYKER REST. MOD. HIP SYSTEM 6276-7-016	278	RC	C1776	CPT				Both			11677.05	5254.67	5254.67	10509.35		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	8641.02							Fee Schedule																													10509.35							Fee Schedule																																															
STRYKER RET. FEMORAL  5510-F-302	278	RC	C1776	CPT				Both			5827.5	2622.38	2622.38	5244.75		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	4312.35							Fee Schedule																													5244.75							Fee Schedule																																															
STRYKER RET. FEMORAL  5510-F-601	278	RC	C1776	CPT				Both			5827.5	2622.38	2622.38	5244.75		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	4312.35							Fee Schedule																													5244.75							Fee Schedule																																															
STRYKER REVOLUTION MIX 0606-573-000	272	RC						Both			445.2	200.34	200.34	400.68	289.38							Fee Schedule		329.45							Fee Schedule																													400.68							Fee Schedule																																															
STRYKER RND.BURR #1608-6-91	272	RC						Both			311.85	140.33	140.33	280.67	202.7							Fee Schedule		230.77							Fee Schedule																													280.67							Fee Schedule																																															
STRYKER RND.BURR #1608-6-99	272	RC						Both			225.75	101.59	101.59	203.18	146.74							Fee Schedule		167.06							Fee Schedule																													203.18							Fee Schedule																																															
STRYKER SAGITTAL BLADE 6113-127-060	272	RC						Both			175	78.75	78.75	157.5	113.75							Fee Schedule		129.5							Fee Schedule																													157.5							Fee Schedule																																															
STRYKER SAGITTAL BLADE 6118-127-090	272	RC						Both			175	78.75	78.75	157.5	113.75							Fee Schedule		129.5							Fee Schedule																													157.5							Fee Schedule																																															
STRYKER SERF.ENERG. HOOK #279-350-501	272	RC						Both			405.3	182.39	182.39	364.77	263.45							Fee Schedule		299.92							Fee Schedule																													364.77							Fee Schedule																																															
STRYKER SHOWER HEAD TIP #207-53	272	RC						Both			56.7	25.52	25.52	51.03	36.86							Fee Schedule		41.96							Fee Schedule																													51.03							Fee Schedule																																															
STRYKER SLEEVE # 6942-6-060	278	RC	C1776	CPT				Both			647.85	291.53	291.53	583.07		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	479.41							Fee Schedule																													583.07							Fee Schedule																																															
STRYKER SMART TOE   STOA-19P	278	RC	C1776	CPT				Both			3024	1360.8	1360.8	2721.6		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	2237.76							Fee Schedule																													2721.6							Fee Schedule																																															
STRYKER SMART TOE  STOA-22P	278	RC	C1776	CPT				Both			3024	1360.8	1360.8	2721.6		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	2237.76							Fee Schedule																													2721.6							Fee Schedule																																															
STRYKER SMOKE EVAC PENCIL 0703-046-000	272	RC						Both			70	31.5	31.5	63	45.5							Fee Schedule		51.8							Fee Schedule																													63							Fee Schedule																																															
STRYKER STAB. FEM. COMP.  5512-F-401	278	RC	C1776	CPT				Both			17928.75	8067.94	8067.94	16135.88		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	13267.28							Fee Schedule																													16135.88							Fee Schedule																																															
STRYKER SURGILAV #207-553	272	RC						Both			136.5	61.43	61.43	122.85	88.73							Fee Schedule		101.01							Fee Schedule																													122.85							Fee Schedule																																															
STRYKER SUTURE ANCH. # OOCAT01858	278	RC	C1713	CPT				Both			1212.75	545.74	545.74	1091.48		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	897.44							Fee Schedule																													1091.48							Fee Schedule																																															
STRYKER SUTURE SLIDER #3910-000-100	272	RC						Both			453.6	204.12	204.12	408.24	294.84							Fee Schedule		335.66							Fee Schedule																													408.24							Fee Schedule																																															
STRYKER SUTURE SLIDER #3910-000-101	272	RC						Both			453.6	204.12	204.12	408.24	294.84							Fee Schedule		335.66							Fee Schedule																													408.24							Fee Schedule																																															
STRYKER SUTURE SLIDER #3910-000-102	272	RC						Both			453.6	204.12	204.12	408.24	294.84							Fee Schedule		335.66							Fee Schedule																													408.24							Fee Schedule																																															
STRYKER SUTURE SLIDER #3910-000-103	272	RC						Both			453.6	204.12	204.12	408.24	294.84							Fee Schedule		335.66							Fee Schedule																													408.24							Fee Schedule																																															
STRYKER SUTURE SLIDER #3910-000-104	272	RC						Both			453.6	204.12	204.12	408.24	294.84							Fee Schedule		335.66							Fee Schedule																													408.24							Fee Schedule																																															
STRYKER TIBIAL BASEPLATE  5521-B-700	278	RC	C1776	CPT				Both			5355	2409.75	2409.75	4819.5		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	3962.7							Fee Schedule																													4819.5							Fee Schedule																																															
STRYKER TIBIAL BASEPLATE # 5520-B-300	278	RC	C1776	CPT				Both			3465	1559.25	1559.25	3118.5		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	2564.1							Fee Schedule																													3118.5							Fee Schedule																																															
STRYKER TIBIAL BASEPLATE #5521-B-600	278	RC	C1776	CPT				Both			5355	2409.75	2409.75	4819.5		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	3962.7							Fee Schedule																													4819.5							Fee Schedule																																															
STRYKER TIBIAL BEARING  5531-P-611	278	RC	C1776	CPT				Both			2677.5	1204.88	1204.88	2409.75		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1981.35							Fee Schedule																													2409.75							Fee Schedule																																															
STRYKER TIBIAL BEARING  5532-P-713	278	RC	C1776	CPT				Both			2677.5	1204.88	1204.88	2409.75		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1981.35							Fee Schedule																													2409.75							Fee Schedule																																															
STRYKER TIBIAL BEARING 5531-P-311	278	RC	C1776	CPT				Both			2677.5	1204.88	1204.88	2409.75		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1981.35							Fee Schedule																													2409.75							Fee Schedule																																															
STRYKER TIBIAL BEARING 5532-P-311	278	RC	C1776	CPT				Both			2677.5	1204.88	1204.88	2409.75		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1981.35							Fee Schedule																													2409.75							Fee Schedule																																															
STRYKER TIBIAL PLATE  5521-B-300	278	RC	C1776	CPT				Both			5355	2409.75	2409.75	4819.5		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	3962.7							Fee Schedule																													4819.5							Fee Schedule																																															
STRYKER TOGA GOWN # 400-820	272	RC						Both			153.3	68.99	68.99	137.97	99.65							Fee Schedule		113.44							Fee Schedule																													137.97							Fee Schedule																																															
STRYKER TOGA L/XL  0400-820-000	272	RC						Both			153.3	68.99	68.99	137.97	99.65							Fee Schedule		113.44							Fee Schedule																													137.97							Fee Schedule																																															
STRYKER TROCH. LOCK NAIL #3370-8-130	278	RC	C1713	CPT				Both			2608.2	1173.69	1173.69	2347.38		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1930.07							Fee Schedule																													2347.38							Fee Schedule																																															
STRYKER TWINLOOP 3.5 #3910-405-638	278	RC	C1713	CPT				Both			1155	519.75	519.75	1039.5		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	854.7							Fee Schedule																													1039.5							Fee Schedule																																															
STRYKER TWINLOOP FLEX DRIL #3910-400-100	272	RC						Both			719.25	323.66	323.66	647.33	467.51							Fee Schedule		532.25							Fee Schedule																													647.33							Fee Schedule																																															
STRYKER UNIVERSAL HEAD #UH1-48-26	278	RC	C1776	CPT				Both			3969	1786.05	1786.05	3572.1		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	2937.06							Fee Schedule																													3572.1							Fee Schedule																																															
STRYKER UNIVERSAL HEAD #UH1-51-26	278	RC	C1776	CPT				Both			2362.5	1063.13	1063.13	2126.25		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1748.25							Fee Schedule																													2126.25							Fee Schedule																																															
STRYKER UNIVERSAL HEAD #UH1-56-26	278	RC	C1776	CPT				Both			2362.5	1063.13	1063.13	2126.25		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1748.25							Fee Schedule																													2126.25							Fee Schedule																																															
STRYKER VAC.MIX BOWL #206-553	272	RC						Both			281.4	126.63	126.63	253.26	182.91							Fee Schedule		208.24							Fee Schedule																													253.26							Fee Schedule																																															
STRYKER VERSATOMIC REAMER #234-030-010-R	272	RC						Both			1559.25	701.66	701.66	1403.33	1013.51							Fee Schedule		1153.85							Fee Schedule																													1403.33							Fee Schedule																																															
STRYKER VERSATOMIC REAMER #234-108-000-R	272	RC						Both			929.25	418.16	418.16	836.33	604.01							Fee Schedule		687.65							Fee Schedule																													836.33							Fee Schedule																																															
STRYKER VITALLIUM WIRE #2703-3-020	272	RC						Both			23.1	10.4	10.4	20.79	15.02							Fee Schedule		17.09							Fee Schedule																													20.79							Fee Schedule																																															
STRYKER YELLOW CARTRIDGE 240-080-203	270	RC						Both			6.3	2.84	2.84	5.67	4.1							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
STYKER LONG TIP BLADE 385-544-000	272	RC						Both			1157.1	520.7	520.7	1041.39	752.12							Fee Schedule		856.25							Fee Schedule																													1041.39							Fee Schedule																																															
STYLET ADULT 14 FR. 4.7MM DYNJSTY14F	272	RC						Both			5	2.25	2.25	4.5	3.25							Fee Schedule		3.7							Fee Schedule																													4.5							Fee Schedule																																															
STYRENE 38230 WHOLE BLOOD LAV	301	RC	84600	CPT				Both			236.25	106.31	14.29	212.63	14.29							Fee Schedule		17.87							Fee Schedule		17.62							Fee Schedule		17.11							Fee Schedule											212.63							Fee Schedule																				17.11							Fee Schedule																				
SUB CLAVIAN	272	RC						Both			50.4	22.68	22.68	45.36	32.76							Fee Schedule		37.3							Fee Schedule																													45.36							Fee Schedule																																															
SUCCINYLCHOLINE 20 MG/ML-10ML MDV	636	RC	J0330	CPT				Both			6	2.7	1.09	5.4		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	4.44							Fee Schedule											1.09							Fee Schedule											5.4							Fee Schedule																																															
SUCCINYLCHOLINE 20 MG/ML-10ML SYR (QUVA)	636	RC	J0330	CPT				Both			94.86	42.69	1.09	85.37		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	70.2							Fee Schedule											1.09							Fee Schedule		17.11							Fee Schedule		85.37							Fee Schedule		19.68							Fee Schedule		15.91							Fee Schedule											19.68							Fee Schedule		15.91							Fee Schedule		
SUCRALFATE 1 GM/10ML ORAL SUSP UD-10ML	250	RC	A9270	CPT				Both			35.7	16.07	0.01	32.13	0.01							Fee Schedule		26.42							Fee Schedule																													32.13							Fee Schedule																																															
SUCRALFATE 1GM (CARAFATE) TABLET	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
SUCTION BEEBOP PREMIE #N204 (SENECA)	272	RC						Both			7.35	3.31	3.31	6.62	4.78							Fee Schedule		5.44							Fee Schedule																													6.62							Fee Schedule																																															
SUCTION BOTTLE O.R. (DEROYAL)	270	RC						Both			13.65	6.14	6.14	12.29	8.87							Fee Schedule		10.1							Fee Schedule																													12.29							Fee Schedule																																															
SUCTION CANISTER B1605  DEVICOR	271	RC	A7000	CPT				Both			40	18	6.56	36	6.56							Fee Schedule		29.6							Fee Schedule		10.82							Fee Schedule																				36							Fee Schedule																																															
SUCTION CANISTER HI-FLOW  484410	271	RC	A7000	CPT				Both			16	7.2	6.56	14.4	6.56							Fee Schedule		11.84							Fee Schedule		10.82							Fee Schedule																				14.4							Fee Schedule																																															
SUCTION CANNISTER	271	RC						Both			11.55	5.2	5.2	10.4	7.51							Fee Schedule		8.55							Fee Schedule																													10.4							Fee Schedule																																															
SUCTION CANNISTER OMNI-JUG 5036-00 DEROY	270	RC						Both			49	22.05	9.77	44.1	31.85							Fee Schedule		36.26							Fee Schedule																				10.5							Fee Schedule		44.1							Fee Schedule		12.08							Fee Schedule		9.77							Fee Schedule											12.08							Fee Schedule		9.77							Fee Schedule		
SUCTION CATH 10FR DYND41900H	272	RC						Both			2	0.9	0.9	12.08	1.3							Fee Schedule		1.48							Fee Schedule																				10.5							Fee Schedule		1.8							Fee Schedule		12.08							Fee Schedule		9.77							Fee Schedule											12.08							Fee Schedule		9.77							Fee Schedule		
SUCTION CATH 10FR.	272	RC						Both			3	1.35	1.35	2.7	1.95							Fee Schedule		2.22							Fee Schedule																													2.7							Fee Schedule																																															
SUCTION CATH 14FR DYND41902	272	RC						Both			2	0.9	0.9	1.8	1.3							Fee Schedule		1.48							Fee Schedule																													1.8							Fee Schedule																																															
SUCTION CATH 14FR.#31420	272	RC						Both			2.1	0.95	0.95	1.89	1.37							Fee Schedule		1.55							Fee Schedule																													1.89							Fee Schedule																																															
SUCTION CATH 8FR. DYND41908	272	RC						Both			1	0.45	0.45	0.9	0.65							Fee Schedule		0.74							Fee Schedule																													0.9							Fee Schedule																																															
SUCTION CATH IN LINE #DYNCPTP14	272	RC	A4605	CPT				Both			26	11.7	11.7	24.08	14.77							Fee Schedule		19.24							Fee Schedule		24.08							Fee Schedule																				23.4							Fee Schedule																																															
SUCTION CATH TRAY W/ CHIMNEY VALUE 37024	272	RC						Both			2.5	1.13	1.13	2.25	1.63							Fee Schedule		1.85							Fee Schedule																													2.25							Fee Schedule																																															
SUCTION CATHETER KIT 31479	272	RC						Both			3.15	1.42	1.42	2.84	2.05							Fee Schedule		2.33							Fee Schedule																													2.84							Fee Schedule																																															
SUCTION COAGULATOR 050-040 (ZIMMER)	272	RC						Both			40	18	18	36	26							Fee Schedule		29.6							Fee Schedule																				23.38							Fee Schedule		36							Fee Schedule		26.89							Fee Schedule		21.74							Fee Schedule											26.89							Fee Schedule		21.74							Fee Schedule		
SUCTION COAGULATOR 10FR 88-2505-10F	272	RC						Both			39	17.55	17.55	35.1	25.35							Fee Schedule		28.86							Fee Schedule																													35.1							Fee Schedule																																															
SUCTION IRRIGATOR #0026880 (DAVOL)	272	RC						Both			126	56.7	56.7	113.4	81.9							Fee Schedule		93.24							Fee Schedule																													113.4							Fee Schedule																																															
SUCTION IRRIGATOR (STRYKER ENDOSCOPY)	272	RC						Both			197.4	88.83	88.83	177.66	128.31							Fee Schedule		146.08							Fee Schedule																													177.66							Fee Schedule																																															
SUCTION KITS	272	RC						Both			7.35	3.31	3.31	6.62	4.78							Fee Schedule		5.44							Fee Schedule																													6.62							Fee Schedule																																															
SUCTION SPECIMEN VALVE MAJ-209	271	RC						Both			39	17.55	17.55	35.1	25.35							Fee Schedule		28.86							Fee Schedule																													35.1							Fee Schedule																																															
SUCTION TRAP 40CC	272	RC						Both			6.3	2.84	2.84	5.67	4.1							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
SUCTION TUBE	272	RC						Both			5.25	2.36	2.36	4.73	3.41							Fee Schedule		3.89							Fee Schedule																													4.73							Fee Schedule																																															
SUDAFED C SYR PER OZ	250	RC	A9270	CPT				Both			2.68	1.21	0.01	2.41	0.01							Fee Schedule		1.98							Fee Schedule																													2.41							Fee Schedule																																															
SUDAFED SYRUP 15 MG/5ML LIQUID UD	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
SUDAN STAIN 3967 STOOL	301	RC	82705	CPT				Both			27.3	12.29	4.53	24.57	4.53							Fee Schedule		5.66							Fee Schedule		5.25							Fee Schedule		5.1							Fee Schedule											24.57							Fee Schedule																				5.1							Fee Schedule																				
SUDOGEST (PSEUDOEPHEDRINE) 30MG TABLET	250	RC	A9270	CPT				Both			5.25	2.36	0.01	4.73	0.01							Fee Schedule		3.89							Fee Schedule																													4.73							Fee Schedule																																															
SUFENTANIL 50 MCG/ML- 2ML AMPULE	250	RC						Both			73.5	33.08	33.08	66.15	47.78							Fee Schedule		54.39							Fee Schedule																													66.15							Fee Schedule																																															
SUGAR TONG ANKLE BILATER  2  ORTHO GLASS	274	RC	A4590	CPT				Both			680.4	306.18	4.74	612.36		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	503.5							Fee Schedule											24.09							Fee Schedule		5.1							Fee Schedule		612.36							Fee Schedule		5.87							Fee Schedule		4.74							Fee Schedule											5.87							Fee Schedule		4.74							Fee Schedule		
SUGAR TONG ANKLE BILATER  3  ORTHO GLASS	274	RC	A4590	CPT				Both			907.2	408.24	24.09	816.48		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	671.33							Fee Schedule											24.09							Fee Schedule											816.48							Fee Schedule																																															
SUGAR TONG ANKLE BILATER  4  ORTHO GLASS	274	RC	A4590	CPT				Both			1134	510.3	24.09	1020.6		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	839.16							Fee Schedule											24.09							Fee Schedule											1020.6							Fee Schedule																																															
SUGAR TONG ANKLE BILATER  5  ORTHO GLASS	274	RC	A4590	CPT				Both			1360.8	612.36	24.09	1224.72		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1006.99							Fee Schedule											24.09							Fee Schedule											1224.72							Fee Schedule																																															
SUGAR TONG ANKLE R & L  2  ORTHO GLASS	274	RC	A4590	CPT				Both			340.2	153.09	24.09	306.18		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	251.75							Fee Schedule											24.09							Fee Schedule											306.18							Fee Schedule																																															
SUGAR TONG ANKLE R & L  3  ORTHO GLASS	270	RC						Both			453.6	204.12	204.12	408.24	294.84							Fee Schedule		335.66							Fee Schedule																													408.24							Fee Schedule																																															
SUGAR TONG ANKLE R & L  4  ORTHO GLASS	270	RC						Both			567	255.15	255.15	510.3	368.55							Fee Schedule		419.58							Fee Schedule																													510.3							Fee Schedule																																															
SUGAR TONG ANKLE R & L  5  ORTHO GLASS	274	RC	A4590	CPT				Both			680.4	306.18	24.09	612.36		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	503.5							Fee Schedule											24.09							Fee Schedule											612.36							Fee Schedule																																															
SUGAR TONG BILATERAL 2  ORTHO GLASS	274	RC	A4590	CPT				Both			567	255.15	24.09	510.3		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	419.58							Fee Schedule											24.09							Fee Schedule											510.3							Fee Schedule																																															
SUGAR TONG BILATERAL 3  ORTHO GLASS	274	RC	A4590	CPT				Both			756	340.2	24.09	680.4		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	559.44							Fee Schedule											24.09							Fee Schedule											680.4							Fee Schedule																																															
SUGAR TONG BILATERAL 4  ORTHO GLASS	274	RC	A4590	CPT				Both			945	425.25	24.09	850.5		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	699.3							Fee Schedule											24.09							Fee Schedule											850.5							Fee Schedule																																															
SUGAR TONG BILATERAL 5  ORTHO GLASS	274	RC	A4590	CPT				Both			1134	510.3	24.09	1020.6		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	839.16							Fee Schedule											24.09							Fee Schedule											1020.6							Fee Schedule																																															
SUGAR TONG SPLINT R & L 2  ORTHO GLASS	270	RC						Both			283.5	127.58	127.58	255.15	184.28							Fee Schedule		209.79							Fee Schedule																													255.15							Fee Schedule																																															
SUGAR TONG SPLINT R & L 3  ORTHO GLASS	270	RC						Both			378	170.1	170.1	340.2	245.7							Fee Schedule		279.72							Fee Schedule																													340.2							Fee Schedule																																															
SUGAR TONG SPLINT R & L 4  ORTHO GLASS	270	RC						Both			472.5	212.63	212.63	425.25	307.13							Fee Schedule		349.65							Fee Schedule																													425.25							Fee Schedule																																															
SUGAR TONG SPLINT R & L 5  ORTHO GLASS	274	RC	A4590	CPT				Both			567	255.15	24.09	510.3		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	419.58							Fee Schedule											24.09							Fee Schedule											510.3							Fee Schedule																																															
SUIPART 12MM	272	RC						Both			313.95	141.28	141.28	282.56	204.07							Fee Schedule		232.32							Fee Schedule																													282.56							Fee Schedule																																															
SULFACETAMIDE SODIUM 10% OPTH SOLN-15ML	250	RC	A9270	CPT				Both			175.35	78.91	0.01	157.82	0.01							Fee Schedule		129.76							Fee Schedule																													157.82							Fee Schedule																																															
SULFACETMIDE SODIUM 10% OPTH OINT- 3.5GM	250	RC	A9270	CPT				Both			25.73	11.58	0.01	23.16	0.01							Fee Schedule		19.04							Fee Schedule																													23.16							Fee Schedule																																															
SULFAMET/TRIM 200-40 MG/5ML OS BOTTLE-UD	250	RC	A9270	CPT				Both			14.84	6.68	0.01	13.36	0.01							Fee Schedule		10.98							Fee Schedule																													13.36							Fee Schedule																																															
SULFAMET/TRIM 800MG/160MG PER 20ML/ UD	250	RC	A9270	CPT				Both			26.25	11.81	0.01	23.63	0.01							Fee Schedule		19.43							Fee Schedule																													23.63							Fee Schedule																																															
SULFAMET/TRIM 800MG/160MG PER 20ML/ UD	250	RC	A9270	CPT				Both			12.6	5.67	0.01	11.34	0.01							Fee Schedule		9.32							Fee Schedule																													11.34							Fee Schedule																																															
SULFAMET/TRIM 800MG-160MG/10ML VIAL	250	RC	J2865	CPT				Both			47.25	21.26	0.04	42.53	30.71							Fee Schedule		34.97							Fee Schedule		0.04							Fee Schedule																				42.53							Fee Schedule																																															
SULFAMETHOXAZOLE/TMP 800-160 TABLET	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
SULFASALAZINE 500MG (AZULFIDINE) TABLET	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
SULINDAC 150 MG TABLET UD	250	RC	A9270	CPT				Both			5.25	2.36	0.01	4.73	0.01							Fee Schedule		3.89							Fee Schedule																				0.04							Fee Schedule		4.73							Fee Schedule		0.04							Fee Schedule		0.03							Fee Schedule											0.04							Fee Schedule		0.03							Fee Schedule		
SULINDAC 200MG (CLINORIL) TABLET	250	RC	A9270	CPT				Both			5.25	2.36	0.01	4.73	0.01							Fee Schedule		3.89							Fee Schedule																													4.73							Fee Schedule																																															
SUMATRIPTAN 50MG  (IMITREX) TABLET	250	RC	A9270	CPT				Both			78.75	35.44	0.01	70.88	0.01							Fee Schedule		58.28							Fee Schedule																													70.88							Fee Schedule																																															
SUMATRIPTAN 6MG/0.5ML(IMITREX) INJECTION	636	RC	J3030	CPT				Both			267.75	120.49	44.55	240.98		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	198.14							Fee Schedule											44.55							Fee Schedule											240.98							Fee Schedule																																															
SUMYCIN SYRUP 125MG	250	RC	A9270	CPT				Both			2.05	0.92	0.01	1.85	0.01							Fee Schedule		1.52							Fee Schedule																													1.85							Fee Schedule																																															
SUNMED AIRWAY 70MM 1-1505-70	271	RC						Both			3.15	1.42	1.42	2.84	2.05							Fee Schedule		2.33							Fee Schedule																													2.84							Fee Schedule																																															
SUNMED AIRWAY 80MM 1-1505-80	271	RC						Both			3.15	1.42	1.42	2.84	2.05							Fee Schedule		2.33							Fee Schedule																													2.84							Fee Schedule																																															
SUNMED AIRWAY 90MM 1-1505-90	271	RC						Both			3.15	1.42	1.42	2.84	2.05							Fee Schedule		2.33							Fee Schedule																													2.84							Fee Schedule																																															
SUPARTZ-FX 2.5ML SINGLE-USE SYRINGE	636	RC	J7321	CPT				Both			220.5	99.23	72.39	198.45		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	163.17							Fee Schedule		72.39							Fee Schedule																				198.45							Fee Schedule																																															
SUPER MULTIVAC ASC4250-01  MEDLINE	272	RC						Both			234	105.3	105.3	210.6	152.1							Fee Schedule		173.16							Fee Schedule																													210.6							Fee Schedule																																															
SUPLENA 240ML CAN	250	RC						Both			10.5	4.73	4.73	9.45	6.83							Fee Schedule		7.77							Fee Schedule																													9.45							Fee Schedule																																															
SUPLENA PER CAN + MF	250	RC						Both			12.86	5.79	5.79	80.82	8.36							Fee Schedule		9.52							Fee Schedule																				70.28							Fee Schedule		11.57							Fee Schedule		80.82							Fee Schedule		65.36							Fee Schedule											80.82							Fee Schedule		65.36							Fee Schedule		
SUPLENA W/CARB STEADY-237ML	250	RC	B4154	CPT				Both			12.69	5.71	0.36	11.42	0.36							Fee Schedule		9.39							Fee Schedule											2.21							Fee Schedule											11.42							Fee Schedule																																															
SUPRA PUBIC CATH SET	272	RC						Both			174.3	78.44	78.44	156.87	113.3							Fee Schedule		128.98							Fee Schedule																													156.87							Fee Schedule																																															
SUPRA PUBIC FOLEY CATH. SET (BARD)143112	272	RC	C2627	CPT				Both			259.35	116.71	73.04	233.42	73.04							Fee Schedule		191.92							Fee Schedule																													233.42							Fee Schedule																																															
SUPRAMID 3-0  CP-30 (SENECA)	272	RC						Both			13.65	6.14	6.14	12.29	8.87							Fee Schedule		10.1							Fee Schedule																													12.29							Fee Schedule																																															
SUPRAMID 4-0  CP-40 (SENECA)	272	RC						Both			13.65	6.14	6.14	12.29	8.87							Fee Schedule		10.1							Fee Schedule																													12.29							Fee Schedule																																															
SUPRANE-240ML   (EACH)	250	RC						Both			605.85	272.63	272.63	545.27	393.8							Fee Schedule		448.33							Fee Schedule																													545.27							Fee Schedule																																															
SURE VUE SIGNATURE MONO TEST 23-200-275	270	RC						Both			5	2.25	2.25	4.5	3.25							Fee Schedule		3.7							Fee Schedule																													4.5							Fee Schedule																																															
SURE VUE SIGNATURE STREP A TEST	270	RC						Both			3	1.35	1.35	2.7	1.95							Fee Schedule		2.22							Fee Schedule																													2.7							Fee Schedule																																															
SUREPREP RAPID DRY SPRAY 28ML #MSC1528	272	RC	A4369	CPT				Both			19	8.55	2.18	17.1	2.18							Fee Schedule		14.06							Fee Schedule		3.56							Fee Schedule																				17.1							Fee Schedule																																															
SURESWAB BACTERIAL VAG 10123	306	RC	87151	CPT				Both			500	225	225	450	325							Fee Schedule		370							Fee Schedule																													450							Fee Schedule																																															
SURESWAB VAGINOSIS/VAGINITIS 14577	306	RC	87510	CPT				Both			115.5	51.98	17.83	103.95	17.83							Fee Schedule		22.28							Fee Schedule		20.65							Fee Schedule		20.05							Fee Schedule											103.95							Fee Schedule																				20.05							Fee Schedule																				
SURG PATH EXAM LEV 4	310	RC	88305	CPT				Both			248.85	111.98	3.22	223.97	19.52							Fee Schedule		27.47							Fee Schedule											31.28							Fee Schedule		3.46							Fee Schedule		223.97							Fee Schedule		3.98							Fee Schedule		3.22							Fee Schedule											3.98							Fee Schedule		3.22							Fee Schedule		
SURGICAL HOOD #4242  (SENECA)	272	RC						Both			2.1	0.95	0.95	1.89	1.37							Fee Schedule		1.55							Fee Schedule																													1.89							Fee Schedule																																															
SURGICEL  1952S	272	RC						Both			344	154.8	18.65	309.6	223.6							Fee Schedule		254.56							Fee Schedule																				20.05							Fee Schedule		309.6							Fee Schedule		23.06							Fee Schedule		18.65							Fee Schedule											23.06							Fee Schedule		18.65							Fee Schedule		
SURGICEL NU-KNIT 3X4  1943S	272	RC						Both			303	136.35	136.35	272.7	196.95							Fee Schedule		224.22							Fee Schedule																													272.7							Fee Schedule																																															
SURGIFLO 8ML HEMOSTATIC MATRIX #2991	272	RC						Both			594.3	267.44	267.44	534.87	386.3							Fee Schedule		439.78							Fee Schedule																													534.87							Fee Schedule																																															
SURGIFLO ENDO. APPLICATOR #MS1995	272	RC						Both			236.25	106.31	106.31	212.63	153.56							Fee Schedule		174.83							Fee Schedule																													212.63							Fee Schedule																																															
SURGIFLO HEMOSTATIC W/ THROMBIN   2994	272	RC						Both			853.23	383.95	383.95	767.91	554.6							Fee Schedule		631.39							Fee Schedule																													767.91							Fee Schedule																																															
SURGIFOAM ABSORB GEL SPONGE 2X6CM 1972	272	RC						Both			20	9	9	18	13							Fee Schedule		14.8							Fee Schedule																													18							Fee Schedule																																															
SURGILENE (5.0)341623	272	RC						Both			28.35	12.76	12.76	25.52	18.43							Fee Schedule		20.98							Fee Schedule																													25.52							Fee Schedule																																															
SURGILENE 4.0 341633	272	RC						Both			24.15	10.87	10.87	21.74	15.7							Fee Schedule		17.87							Fee Schedule																													21.74							Fee Schedule																																															
SURGIMESH  # T221510	278	RC	C1781	CPT				Both			2661.75	1197.79	1197.79	2395.58		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1969.7							Fee Schedule																													2395.58							Fee Schedule																																															
SURGIMESH  #TINTRAC10	278	RC	C1781	CPT				Both			3433.5	1545.08	1545.08	3090.15		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	2540.79							Fee Schedule																													3090.15							Fee Schedule																																															
SURGIMESH  #TINTRAR1415	278	RC	C1781	CPT				Both			4583.25	2062.46	2062.46	4124.93		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	3391.61							Fee Schedule																													4124.93							Fee Schedule																																															
SURGIMESH 15CM  #TINTRAC15	278	RC	C1781	CPT				Both			5229	2353.05	2353.05	4706.1		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	3869.46							Fee Schedule																													4706.1							Fee Schedule																																															
SURGIMESH 2X4 # T510  ( BG MEDICAL )	278	RC	C1781	CPT				Both			765	344.25	344.25	688.5		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	566.1							Fee Schedule																													688.5							Fee Schedule																																															
SURGIMESH 7MM SKIRTED #TINTRACK7	278	RC	C1781	CPT				Both			2677.5	1204.88	1204.88	2409.75		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1981.35							Fee Schedule																													2409.75							Fee Schedule																																															
SURGIMESH MESH TINTRAC 12	278	RC	C1781	CPT				Both			4567.5	2055.38	2055.38	4110.75		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	3379.95							Fee Schedule																													4110.75							Fee Schedule																																															
SURGIMESH T1015  ( BG MEDICAL )	278	RC	C1781	CPT				Both			1338.75	602.44	602.44	1204.88		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	990.68							Fee Schedule																													1204.88							Fee Schedule																																															
SURGIMESH XB 15X22 # TINTRAE1522 ( BG ME	278	RC	C1781	CPT				Both			7717.5	3472.88	3472.88	6945.75		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	5710.95							Fee Schedule																													6945.75							Fee Schedule																																															
SURVANTA SUSPENSION 25MG/ML-8ML	636	RC						Both			2440.38	1098.17	1098.17	2196.34		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1805.88							Fee Schedule																													2196.34							Fee Schedule																																															
SUSPENSORY BELT	271	RC						Both			24.15	10.87	10.87	21.74	15.7							Fee Schedule		17.87							Fee Schedule																													21.74							Fee Schedule																																															
SUS-PHRINE INJ:.3ML	636	RC	J0171	CPT				Both			11.31	5.09	5.09	10.18		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	8.37							Fee Schedule																													10.18							Fee Schedule																																															
SUTURE CARTRIDGE OM8175	272	RC						Both			510.3	229.64	229.64	459.27	331.7							Fee Schedule		377.62							Fee Schedule																													459.27							Fee Schedule																																															
SUTURE DAVIS TONSIL NEEDLE 3/8 # 219500	272	RC						Both			15.75	7.09	7.09	14.18	10.24							Fee Schedule		11.66							Fee Schedule																													14.18							Fee Schedule																																															
SUTURE PASSER SLEEVES #1GSP02 ( WL GORE	272	RC						Both			389.55	175.3	175.3	350.6	253.21							Fee Schedule		288.27							Fee Schedule																													350.6							Fee Schedule																																															
SUTURE RETRIEVER  LINVATEC	272	RC						Both			169.05	76.07	76.07	152.15	109.88							Fee Schedule		125.1							Fee Schedule																													152.15							Fee Schedule																																															
SUTURE SHUTTLE 25 DEGREE LEFT #251001	272	RC						Both			633	284.85	284.85	569.7	411.45							Fee Schedule		468.42							Fee Schedule																													569.7							Fee Schedule																																															
SUTURE SHUTTLE 25 DEGREE RIGHT #251002	272	RC						Both			696	313.2	313.2	626.4	452.4							Fee Schedule		515.04							Fee Schedule																													626.4							Fee Schedule																																															
SUTURE SHUTTLE 45 DEGREE LEFT 251003 J&J	272	RC						Both			696	313.2	313.2	626.4	452.4							Fee Schedule		515.04							Fee Schedule																													626.4							Fee Schedule																																															
SUTURE SHUTTLE 45 DEGREE RIGHT #251004	272	RC						Both			585	263.25	263.25	526.5	380.25							Fee Schedule		432.9							Fee Schedule																													526.5							Fee Schedule																																															
SUTURE SHUTTLE 90 DEGREE UP #251005 J&J	272	RC						Both			633	284.85	284.85	569.7	411.45							Fee Schedule		468.42							Fee Schedule																													569.7							Fee Schedule																																															
SUTURE SHUTTLE CRESCENT #251007 J&J	272	RC						Both			696	313.2	313.2	626.4	452.4							Fee Schedule		515.04							Fee Schedule																													626.4							Fee Schedule																																															
SUTURE TRAY DISP. SAFETY #DYNJ03013	270	RC						Both			26	11.7	11.7	23.4	16.9							Fee Schedule		19.24							Fee Schedule																													23.4							Fee Schedule																																															
SUTURE X444H	272	RC						Both			40.95	18.43	18.43	36.86	26.62							Fee Schedule		30.3							Fee Schedule																													36.86							Fee Schedule																																															
SUTUREFIX CURVED ANCHOR 1.7MM 72204688	272	RC						Both			811	364.95	364.95	729.9	527.15							Fee Schedule		600.14							Fee Schedule																													729.9							Fee Schedule																																															
SUTUREFIX CURVED DRILL 1.7MM 72204690	272	RC						Both			525	236.25	236.25	472.5	341.25							Fee Schedule		388.5							Fee Schedule																													472.5							Fee Schedule																																															
SUTUREX518H	272	RC						Both			40.95	18.43	18.43	36.86	26.62							Fee Schedule		30.3							Fee Schedule																													36.86							Fee Schedule																																															
SU-TUSS HD ELIXIR 5 ML UD	250	RC	A9270	CPT				Both			4.2	1.89	0.01	3.78	0.01							Fee Schedule		3.11							Fee Schedule																													3.78							Fee Schedule																																															
SWAN GANZ 131F7P	272	RC						Both			220.5	99.23	99.23	198.45	143.33							Fee Schedule		163.17							Fee Schedule																													198.45							Fee Schedule																																															
SWEEN CREAM 3 OZ	250	RC	A9270	CPT				Both			18.9	8.51	0.01	17.01	0.01							Fee Schedule		13.99							Fee Schedule																													17.01							Fee Schedule																																															
SWEEN CREAM:9 OZS	250	RC	A9270	CPT				Both			25.99	11.7	0.01	23.39	0.01							Fee Schedule		19.23							Fee Schedule																													23.39							Fee Schedule																																															
SWEET CHEEKS 40% GLUCOSE GEL	250	RC	A9270	CPT				Both			7.35	3.31	0.01	6.62	0.01							Fee Schedule		5.44							Fee Schedule																													6.62							Fee Schedule																																															
SWEET-EASE NATURAL SUCROSE SOLUTION	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
SWIM/INSTA MOLD (EAR INCORPORATED)	270	RC						Both			18.9	8.51	8.51	17.01	12.29							Fee Schedule		13.99							Fee Schedule																													17.01							Fee Schedule																																															
SWITCH BLADE SCISSOR TIP (GENZYME SURGIC	272	RC						Both			169.05	76.07	76.07	152.15	109.88							Fee Schedule		125.1							Fee Schedule																													152.15							Fee Schedule																																															
SWIVEL CONNECTOR SALTER 1220025	271	RC						Both			3.15	1.42	1.42	2.84	2.05							Fee Schedule		2.33							Fee Schedule																													2.84							Fee Schedule																																															
SYMBICORT 160/4.5 ORAL INHALER-60	250	RC	A9270	CPT				Both			641.55	288.7	0.01	577.4	0.01							Fee Schedule		474.75							Fee Schedule																													577.4							Fee Schedule																																															
SYMBICORT 80/4.5 ORAL INHALER-60	250	RC	A9270	CPT				Both			487.2	219.24	0.01	438.48	0.01							Fee Schedule		360.53							Fee Schedule																													438.48							Fee Schedule																																															
SYMMETRY ANTI-SKI PAD 44X23X1 PRIMEPAD-1	270	RC						Both			173	77.85	77.85	155.7	112.45							Fee Schedule		128.02							Fee Schedule																													155.7							Fee Schedule																																															
SYNAGIS 100 MG VIAL	636	RC	90378	CPT				Both			2100	945	945	1890		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1820.66							Fee Schedule																													1890							Fee Schedule																																															
OTHER O.R. PROCEDURES FOR INJURIES WITH MCC					907	DRG		Inpatient			27970.68	12586.8	12586.8	12586.8							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period	
SYNTH  CORTEX SCREW 201.774	278	RC	C1713	CPT				Both			189	85.05	85.05	170.1		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	139.86							Fee Schedule																													170.1							Fee Schedule																																															
SYNTH  CORTEX SCREW 202.876	278	RC	C1713	CPT				Both			136.5	61.43	61.43	122.85		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	101.01							Fee Schedule																													122.85							Fee Schedule																																															
SYNTH  CORTEX SCREW 202.878	278	RC	C1713	CPT				Both			127.05	57.17	57.17	114.35		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	94.02							Fee Schedule																													114.35							Fee Schedule																																															
SYNTH  PLATE #241.941	278	RC	C1713	CPT				Both			1255.8	565.11	565.11	1130.22		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	929.29							Fee Schedule																													1130.22							Fee Schedule																																															
SYNTH 11MM TI HELICAL BLADE 85MM 456.302	278	RC	C1713	CPT				Both			2668.05	1200.62	1200.62	2401.25		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1974.36							Fee Schedule																													2401.25							Fee Schedule																																															
SYNTH 1-7 CABLE # 298.801.01S	278	RC	C1713	CPT				Both			2191.35	986.11	986.11	1972.22		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1621.6							Fee Schedule																													1972.22							Fee Schedule																																															
SYNTH 2.0 CORTEX SCR. 401.809.96	278	RC	C1713	CPT				Both			151.67	68.25	68.25	136.5		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	112.24							Fee Schedule																													136.5							Fee Schedule																																															
SYNTH 2.0 CORTEX SCR. 401.810.96	278	RC	C1713	CPT				Both			186	83.7	83.7	167.4		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	137.64							Fee Schedule																													167.4							Fee Schedule																																															
SYNTH 2.0 CORTEX SCR. 401.814.96	278	RC	C1713	CPT				Both			162.75	73.24	73.24	146.48		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	120.44							Fee Schedule																													146.48							Fee Schedule																																															
SYNTH 2.4 CORTEX SCREW #401.756	278	RC	C1713	CPT				Both			204.75	92.14	92.14	184.28		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	151.52							Fee Schedule																													184.28							Fee Schedule																																															
SYNTH 2.4 CORTEX SCREW #401.758	278	RC	C1713	CPT				Both			226.8	102.06	102.06	204.12		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	167.83							Fee Schedule																													204.12							Fee Schedule																																															
SYNTH 2.4 CORTEX SCREW #401.760	278	RC	C1713	CPT				Both			250.95	112.93	112.93	225.86		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	185.7							Fee Schedule																													225.86							Fee Schedule																																															
SYNTH 2.4 CORTEX SCREW #401.762	278	RC	C1713	CPT				Both			233.1	104.9	104.9	209.79		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	172.49							Fee Schedule																													209.79							Fee Schedule																																															
SYNTH 2.4 CORTEX SCREW #401.764	278	RC	C1713	CPT				Both			185.85	83.63	83.63	167.27		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	137.53							Fee Schedule																													167.27							Fee Schedule																																															
SYNTH 2.4 CORTEX SCREW #401.766	278	RC	C1713	CPT				Both			238.35	107.26	107.26	214.52		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	176.38							Fee Schedule																													214.52							Fee Schedule																																															
SYNTH 2.4 CORTEX SCREW #401.768	278	RC	C1713	CPT				Both			185.85	83.63	83.63	167.27		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	137.53							Fee Schedule																													167.27							Fee Schedule																																															
SYNTH 2.4 CORTEX SCREW #401.770	278	RC	C1713	CPT				Both			255.15	114.82	114.82	229.64		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	188.81							Fee Schedule																													229.64							Fee Schedule																																															
SYNTH 2.4 CORTEX SCREW #401.772	278	RC	C1713	CPT				Both			244.65	110.09	110.09	220.19		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	181.04							Fee Schedule																													220.19							Fee Schedule																																															
SYNTH 2.4 CORTEX SCREW #401.774	278	RC	C1713	CPT				Both			255.15	114.82	114.82	229.64		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	188.81							Fee Schedule																													229.64							Fee Schedule																																															
SYNTH 2.4 CORTEX SCREW #401.776	278	RC	C1713	CPT				Both			238.35	107.26	107.26	214.52		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	176.38							Fee Schedule																													214.52							Fee Schedule																																															
SYNTH 2.4 CORTEX SCREW #401.778	278	RC	C1713	CPT				Both			255.15	114.82	114.82	229.64		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	188.81							Fee Schedule																													229.64							Fee Schedule																																															
SYNTH 2.4 CORTEX SCREW #401.780	278	RC	C1713	CPT				Both			244.65	110.09	110.09	220.19		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	181.04							Fee Schedule																													220.19							Fee Schedule																																															
SYNTH 2.4 CORTEX SCREW 401.762	278	RC	C1713	CPT				Both			232.05	104.42	104.42	208.85		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	171.72							Fee Schedule																													208.85							Fee Schedule																																															
SYNTH 2.4 LOCK SCREW #412.814	278	RC	C1713	CPT				Both			388.5	174.83	174.83	349.65		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	287.49							Fee Schedule																													349.65							Fee Schedule																																															
SYNTH 2.4 LOCK SCREW #414.818	278	RC	C1713	CPT				Both			340.2	153.09	153.09	306.18		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	251.75							Fee Schedule																													306.18							Fee Schedule																																															
SYNTH 2.4 LOCK SCREW #414.824	278	RC	C1713	CPT				Both			340.2	153.09	153.09	306.18		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	251.75							Fee Schedule																													306.18							Fee Schedule																																															
SYNTH 2.4 LOCK SCREW #414.826	278	RC	C1713	CPT				Both			340.2	153.09	153.09	306.18		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	251.75							Fee Schedule																													306.18							Fee Schedule																																															
SYNTH 2.4 LOCK SCREW 412.810	278	RC	C1713	CPT				Both			371.7	167.27	167.27	334.53		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	275.06							Fee Schedule																													334.53							Fee Schedule																																															
SYNTH 2.4 SCREW #402.874	278	RC	C1713	CPT				Both			198.45	89.3	89.3	178.61		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	146.85							Fee Schedule																													178.61							Fee Schedule																																															
SYNTH 2.4 SCREW #402.876	278	RC	C1713	CPT				Both			124.95	56.23	56.23	112.46		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	92.46							Fee Schedule																													112.46							Fee Schedule																																															
SYNTH 2.4 SCREW #412.812	278	RC	C1713	CPT				Both			388.5	174.83	174.83	349.65		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	287.49							Fee Schedule																													349.65							Fee Schedule																																															
SYNTH 2.4 SCREW #412.816	278	RC	C1713	CPT				Both			388.5	174.83	174.83	349.65		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	287.49							Fee Schedule																													349.65							Fee Schedule																																															
SYNTH 2.4 SCREW #412.818	278	RC	C1713	CPT				Both			388.5	174.83	174.83	349.65		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	287.49							Fee Schedule																													349.65							Fee Schedule																																															
SYNTH 2.4 SCREW #412.820	278	RC	C1713	CPT				Both			388.5	174.83	174.83	349.65		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	287.49							Fee Schedule																													349.65							Fee Schedule																																															
SYNTH 2.4 SCREW #412.822	278	RC	C1713	CPT				Both			388.5	174.83	174.83	349.65		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	287.49							Fee Schedule																													349.65							Fee Schedule																																															
SYNTH 2.4 SCREW #412.824	278	RC	C1713	CPT				Both			363.3	163.49	163.49	326.97		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	268.84							Fee Schedule																													326.97							Fee Schedule																																															
SYNTH 2.4 SCREW #412.826	278	RC	C1713	CPT				Both			368.55	165.85	165.85	331.7		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	272.73							Fee Schedule																													331.7							Fee Schedule																																															
SYNTH 2.4 SCREW #412.828	278	RC	C1713	CPT				Both			368.55	165.85	165.85	331.7		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	272.73							Fee Schedule																													331.7							Fee Schedule																																															
SYNTH 2.4 SCREW #412.830	278	RC	C1713	CPT				Both			340.2	153.09	153.09	306.18		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	251.75							Fee Schedule																													306.18							Fee Schedule																																															
SYNTH 2.4 VOLAR PLATE 442.492	278	RC	C1713	CPT				Both			2898	1304.1	1304.1	2608.2		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	2144.52							Fee Schedule																													2608.2							Fee Schedule																																															
SYNTH 2.7 CORTEX SCREW 402.872	278	RC	C1713	CPT				Both			192.15	86.47	86.47	172.94		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	142.19							Fee Schedule																													172.94							Fee Schedule																																															
SYNTH 2.7 CORTEX SCREW 402.882	278	RC	C1713	CPT				Both			193.2	86.94	86.94	173.88		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	142.97							Fee Schedule																													173.88							Fee Schedule																																															
SYNTH 2.7 CORTEX SCREW 402.884	278	RC	C1713	CPT				Both			193.2	86.94	86.94	173.88		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	142.97							Fee Schedule																													173.88							Fee Schedule																																															
SYNTH 2.7MM TI CORTEX 10MM S/T 402.870	278	RC	C1713	CPT				Both			181.65	81.74	81.74	163.49		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	134.42							Fee Schedule																													163.49							Fee Schedule																																															
SYNTH 2.7MM TI CORTEX 12MM S/T 402.872	278	RC	C1713	CPT				Both			159.6	71.82	71.82	143.64		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	118.1							Fee Schedule																													143.64							Fee Schedule																																															
SYNTH 2.7MM TI CORTEX 14MM S/T 402.874	278	RC	C1713	CPT				Both			159.6	71.82	71.82	143.64		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	118.1							Fee Schedule																													143.64							Fee Schedule																																															
SYNTH 2.7MM TI CORTEX 16MM S/T 402.876	278	RC	C1713	CPT				Both			184.8	83.16	83.16	166.32		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	136.75							Fee Schedule																													166.32							Fee Schedule																																															
SYNTH 2.7MM TI CORTEX 18MM S/T 402.878	278	RC	C1713	CPT				Both			184.8	83.16	83.16	166.32		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	136.75							Fee Schedule																													166.32							Fee Schedule																																															
SYNTH 2.7MM TI CORTEX 20MM S/T 402.880	278	RC	C1713	CPT				Both			184.8	83.16	83.16	166.32		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	136.75							Fee Schedule																													166.32							Fee Schedule																																															
SYNTH 2.7MM TI CORTEX 22MM S/T 402.882	278	RC	C1713	CPT				Both			159.6	71.82	71.82	143.64		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	118.1							Fee Schedule																													143.64							Fee Schedule																																															
SYNTH 2.7MM TI CORTEX 24MM S/T 402.884	278	RC	C1713	CPT				Both			159.6	71.82	71.82	143.64		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	118.1							Fee Schedule																													143.64							Fee Schedule																																															
SYNTH 2.7MM TI CORTEX 26MM S/T 402.886	278	RC	C1713	CPT				Both			159.6	71.82	71.82	143.64		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	118.1							Fee Schedule																													143.64							Fee Schedule																																															
SYNTH 2.7MM TI CORTEX 28MM S/T 402.888	278	RC	C1713	CPT				Both			159.6	71.82	71.82	143.64		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	118.1							Fee Schedule																													143.64							Fee Schedule																																															
SYNTH 2.7MM TI CORTEX 30MM S/T 402.890	278	RC	C1713	CPT				Both			159.6	71.82	71.82	143.64		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	118.1							Fee Schedule																													143.64							Fee Schedule																																															
SYNTH 3.0 SCREW #202.623	278	RC	C1713	CPT				Both			510.3	229.64	229.64	459.27		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	377.62							Fee Schedule																													459.27							Fee Schedule																																															
SYNTH 3.5 CORTEX SCR.FULL THRD. 204.810	278	RC	C1713	CPT				Both			84	37.8	37.8	75.6		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	62.16							Fee Schedule																													75.6							Fee Schedule																																															
SYNTH 3.5 CORTEX SCR.FULL THRD. 204.812	278	RC	C1713	CPT				Both			117	52.65	52.65	105.3		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	86.58							Fee Schedule																													105.3							Fee Schedule																																															
SYNTH 3.5 CORTEX SCR.FULL THRD. 204.814	278	RC	C1713	CPT				Both			117	52.65	52.65	105.3		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	86.58							Fee Schedule																													105.3							Fee Schedule																																															
SYNTH 3.5 CORTEX SCR.FULL THRD. 204.816	278	RC	C1713	CPT				Both			102.9	46.31	46.31	92.61		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	76.15							Fee Schedule																													92.61							Fee Schedule																																															
SYNTH 3.5 CORTEX SCR.FULL THRD. 204.818	278	RC	C1713	CPT				Both			180	81	81	162		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	133.2							Fee Schedule																													162							Fee Schedule																																															
SYNTH 3.5 CORTEX SCR.FULL THRD. 204.820	278	RC	C1713	CPT				Both			102.9	46.31	46.31	92.61		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	76.15							Fee Schedule																													92.61							Fee Schedule																																															
SYNTH 3.5 CORTEX SCR.FULL THRD. 204.822	278	RC	C1713	CPT				Both			172	77.4	77.4	154.8		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	127.28							Fee Schedule																													154.8							Fee Schedule																																															
SYNTH 3.5 CORTEX SCR.FULL THRD. 204.824	278	RC	C1713	CPT				Both			84	37.8	37.8	75.6		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	62.16							Fee Schedule																													75.6							Fee Schedule																																															
SYNTH 3.5 CORTEX SCR.FULL THRD. 204.826	278	RC	C1713	CPT				Both			78.75	35.44	35.44	70.88		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	58.28							Fee Schedule																													70.88							Fee Schedule																																															
SYNTH 3.5 CORTEX SCR.FULL THRD. 204.828	278	RC	C1713	CPT				Both			81.9	36.86	36.86	73.71		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	60.61							Fee Schedule																													73.71							Fee Schedule																																															
SYNTH 3.5 CORTEX SCR.FULL THRD. 204.830	278	RC	C1713	CPT				Both			46.2	20.79	20.79	41.58		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	34.19							Fee Schedule																													41.58							Fee Schedule																																															
SYNTH 3.5 CORTEX SCR.FULL THRD. 204.832	278	RC	C1713	CPT				Both			89.25	40.16	40.16	80.33		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	66.05							Fee Schedule																													80.33							Fee Schedule																																															
SYNTH 3.5 CORTEX SCR.FULL THRD. 204.834	278	RC	C1713	CPT				Both			84	37.8	37.8	75.6		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	62.16							Fee Schedule																													75.6							Fee Schedule																																															
SYNTH 3.5 CORTEX SCR.FULL THRD. 204.836	278	RC	C1713	CPT				Both			110.25	49.61	49.61	99.23		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	81.59							Fee Schedule																													99.23							Fee Schedule																																															
SYNTH 3.5 CORTEX SCR.FULL THRD. 204.838	278	RC	C1713	CPT				Both			46.2	20.79	20.79	41.58		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	34.19							Fee Schedule																													41.58							Fee Schedule																																															
SYNTH 3.5 CORTEX SCR.FULL THRD. 204.840	278	RC	C1713	CPT				Both			46.2	20.79	20.79	41.58		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	34.19							Fee Schedule																													41.58							Fee Schedule																																															
SYNTH 3.5 CORTEX SCR.FULL THRD. 204.845	278	RC	C1713	CPT				Both			110.25	49.61	49.61	99.23		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	81.59							Fee Schedule																													99.23							Fee Schedule																																															
SYNTH 3.5 CORTEX SCR.FULL THRD. 204.850	278	RC	C1713	CPT				Both			117	52.65	52.65	105.3		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	86.58							Fee Schedule																													105.3							Fee Schedule																																															
SYNTH 3.5 LCP PLATE #242.112	278	RC	C1713	CPT				Both			4762.8	2143.26	2143.26	4286.52		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	3524.47							Fee Schedule																													4286.52							Fee Schedule																																															
SYNTH 3.5 PLATE 3 HOLE 241.031	278	RC	C1713	CPT				Both			885.15	398.32	398.32	796.64		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	655.01							Fee Schedule																													796.64							Fee Schedule																																															
SYNTH 4.0 SCREW #458.834	278	RC	C1713	CPT				Both			453.6	204.12	204.12	408.24		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	335.66							Fee Schedule																													408.24							Fee Schedule																																															
SYNTH 4.0 SCREW #458.836	278	RC	C1713	CPT				Both			453.6	204.12	204.12	408.24		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	335.66							Fee Schedule																													408.24							Fee Schedule																																															
SYNTH 4.0 SCREW #458.840	278	RC	C1713	CPT				Both			453.6	204.12	204.12	408.24		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	335.66							Fee Schedule																													408.24							Fee Schedule																																															
SYNTH 4.0 SCREW 04.005.418S	278	RC	C1713	CPT				Both			847.35	381.31	381.31	762.62		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	627.04							Fee Schedule																													762.62							Fee Schedule																																															
SYNTH 4.0 SCREW 04.005.424S	278	RC	C1713	CPT				Both			873.6	393.12	393.12	786.24		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	646.46							Fee Schedule																													786.24							Fee Schedule																																															
SYNTH 4.0 SCREW 04.005.426S	278	RC	C1713	CPT				Both			567	255.15	255.15	510.3		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	419.58							Fee Schedule																													510.3							Fee Schedule																																															
SYNTH 4.0 SCREW 04.005.428S	278	RC	C1713	CPT				Both			876.75	394.54	394.54	789.08		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	648.8							Fee Schedule																													789.08							Fee Schedule																																															
SYNTH 4.0 SCREW 04.005.438S	278	RC	C1713	CPT				Both			708.75	318.94	318.94	637.88		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	524.48							Fee Schedule																													637.88							Fee Schedule																																															
SYNTH 4.0 SHANE PINS #294.769	272	RC						Both			340.2	153.09	153.09	306.18	221.13							Fee Schedule		251.75							Fee Schedule																													306.18							Fee Schedule																																															
SYNTH 4.5 SCREW #212.117	278	RC	C1713	CPT				Both			642	288.9	288.9	577.8		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	475.08							Fee Schedule																													577.8							Fee Schedule																																															
SYNTH 5 HOLE PLATE #241.951	278	RC	C1713	CPT				Both			1020.6	459.27	459.27	918.54		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	755.24							Fee Schedule																													918.54							Fee Schedule																																															
SYNTH 5.0 SCREW #212.118	278	RC	C1713	CPT				Both			527.1	237.2	237.2	474.39		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	390.05							Fee Schedule																													474.39							Fee Schedule																																															
SYNTH 5.0 SHANE PIN 294.784	272	RC						Both			850.5	382.73	382.73	765.45	552.83							Fee Schedule		629.37							Fee Schedule																													765.45							Fee Schedule																																															
SYNTH 8 HOLE PLATE #02..123.026	278	RC	C1713	CPT				Both			5260.5	2367.23	2367.23	4734.45		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	3892.77							Fee Schedule																													4734.45							Fee Schedule																																															
SYNTH BONE VOID FILLER 10CC 07.705.010S	278	RC	C1713	CPT				Both			12768	5745.6	5745.6	11491.2		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	9448.32							Fee Schedule																													11491.2							Fee Schedule																																															
SYNTH CANNULATED NAIL 04.004.252S	278	RC	C1713	CPT				Both			4082.4	1837.08	1837.08	3674.16		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	3020.98							Fee Schedule																													3674.16							Fee Schedule																																															
SYNTH CONDYLER PLATE #02.001.300	278	RC	C1713	CPT				Both			5159.7	2321.87	2321.87	4643.73		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	3818.18							Fee Schedule																													4643.73							Fee Schedule																																															
SYNTH CONDYLER PLATE #02.001.302	278	RC	C1713	CPT				Both			5267.85	2370.53	2370.53	4741.07		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	3898.21							Fee Schedule																													4741.07							Fee Schedule																																															
SYNTH CONDYLER PLATE #02.001.304	278	RC	C1713	CPT				Both			5376	2419.2	2419.2	4838.4		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	3978.24							Fee Schedule																													4838.4							Fee Schedule																																															
SYNTH CONDYLER PLATE #02.001.320	278	RC	C1713	CPT				Both			5159.7	2321.87	2321.87	4643.73		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	3818.18							Fee Schedule																													4643.73							Fee Schedule																																															
SYNTH CONDYLER PLATE #02.001.322	278	RC	C1713	CPT				Both			5267.85	2370.53	2370.53	4741.07		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	3898.21							Fee Schedule																													4741.07							Fee Schedule																																															
SYNTH CONDYLER PLATE #02.001.324	278	RC	C1713	CPT				Both			5376	2419.2	2419.2	4838.4		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	3978.24							Fee Schedule																													4838.4							Fee Schedule																																															
SYNTH COUNTERSINX SCREW 310.89	278	RC	C1713	CPT				Both			1272	572.4	572.4	1144.8		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	941.28							Fee Schedule																													1144.8							Fee Schedule																																															
SYNTH DIST FIBIA LT PLATE 3.5 02.118.400	278	RC	C1713	CPT				Both			3600.45	1620.2	1620.2	3240.41		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	2664.33							Fee Schedule																													3240.41							Fee Schedule																																															
SYNTH DIST FIBIA LT PLATE 3.5 02.118.401	278	RC	C1713	CPT				Both			3600.45	1620.2	1620.2	3240.41		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	2664.33							Fee Schedule																													3240.41							Fee Schedule																																															
SYNTH DIST FIBIA LT PLATE 3.5 02.118.403	278	RC	C1713	CPT				Both			3762.15	1692.97	1692.97	3385.94		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	2783.99							Fee Schedule																													3385.94							Fee Schedule																																															
SYNTH DIST FIBIA LT PLATE 3.5 02.118.405	278	RC	C1713	CPT				Both			3952.2	1778.49	1778.49	3556.98		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	2924.63							Fee Schedule																													3556.98							Fee Schedule																																															
SYNTH DIST FIBIA LT PLATE 3.5 02.118.407	278	RC	C1713	CPT				Both			4150.65	1867.79	1867.79	3735.59		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	3071.48							Fee Schedule																													3735.59							Fee Schedule																																															
SYNTH DIST FIBIA RT PLATE 3.5 02.118.402	278	RC	C1713	CPT				Both			3762.15	1692.97	1692.97	3385.94		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	2783.99							Fee Schedule																													3385.94							Fee Schedule																																															
SYNTH DIST FIBIA RT PLATE 3.5 02.118.404	278	RC	C1713	CPT				Both			3952.2	1778.49	1778.49	3556.98		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	2924.63							Fee Schedule																													3556.98							Fee Schedule																																															
SYNTH DIST FIBIA RT PLATE 3.5 02.118.406	278	RC	C1713	CPT				Both			4392	1976.4	1976.4	3952.8		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	3250.08							Fee Schedule																													3952.8							Fee Schedule																																															
SYNTH DIST FIBIA RT PLATE 3.5 02.118.408	278	RC	C1713	CPT				Both			4345.95	1955.68	1955.68	3911.36		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	3216							Fee Schedule																													3911.36							Fee Schedule																																															
SYNTH DIST FIBIA RT PLATE 3.5 02.118.409	278	RC	C1713	CPT				Both			4345.95	1955.68	1955.68	3911.36		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	3216							Fee Schedule																													3911.36							Fee Schedule																																															
SYNTH DIST TIBIA LT PLATE 3.5 02.118.005	278	RC	C1713	CPT				Both			6657	2995.65	2995.65	5991.3		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	4926.18							Fee Schedule																													5991.3							Fee Schedule																																															
SYNTH DIST TIBIA LT PLATE 3.5 02.118.009	278	RC	C1713	CPT				Both			6792.45	3056.6	3056.6	6113.21		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	5026.41							Fee Schedule																													6113.21							Fee Schedule																																															
SYNTH DIST TIBIA LT PLATE 3.5 02.118.203	278	RC	C1713	CPT				Both			7002.45	3151.1	3151.1	6302.21		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	5181.81							Fee Schedule																													6302.21							Fee Schedule																																															
SYNTH DIST TIBIA LT PLATE 3.5 02.118.205	278	RC	C1713	CPT				Both			7084.88	3188.2	3188.2	6376.39		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	5242.81							Fee Schedule																													6376.39							Fee Schedule																																															
SYNTH DIST TIBIA LT PLATE 3.5 02.118.207	278	RC	C1713	CPT				Both			7161.26	3222.57	3222.57	6445.13		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	5299.33							Fee Schedule																													6445.13							Fee Schedule																																															
SYNTH DIST TIBIA LT PLATE 3.5 02.118.209	278	RC	C1713	CPT				Both			7226.63	3251.98	3251.98	6503.97		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	5347.71							Fee Schedule																													6503.97							Fee Schedule																																															
SYNTH DIST TIBIA RT PLATE 3.5 02.118.002	278	RC	C1713	CPT				Both			6582.98	2962.34	2962.34	5924.68		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	4871.41							Fee Schedule																													5924.68							Fee Schedule																																															
SYNTH DIST TIBIA RT PLATE 3.5 02.118.003	278	RC	C1713	CPT				Both			6582.98	2962.34	2962.34	5924.68		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	4871.41							Fee Schedule																													5924.68							Fee Schedule																																															
SYNTH DIST TIBIA RT PLATE 3.5 02.118.004	278	RC	C1713	CPT				Both			6657	2995.65	2995.65	5991.3		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	4926.18							Fee Schedule																													5991.3							Fee Schedule																																															
SYNTH DIST TIBIA RT PLATE 3.5 02.118.006	278	RC	C1713	CPT				Both			6724.73	3026.13	3026.13	6052.26		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	4976.3							Fee Schedule																													6052.26							Fee Schedule																																															
SYNTH DIST TIBIA RT PLATE 3.5 02.118.007	278	RC	C1713	CPT				Both			6724.73	3026.13	3026.13	6052.26		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	4976.3							Fee Schedule																													6052.26							Fee Schedule																																															
SYNTH DIST TIBIA RT PLATE 3.5 02.118.008	278	RC	C1713	CPT				Both			6792.45	3056.6	3056.6	6113.21		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	5026.41							Fee Schedule																													6113.21							Fee Schedule																																															
SYNTH DIST TIBIA RT PLATE 3.5 02.118.010	278	RC	C1713	CPT				Both			7926.45	3566.9	3566.9	7133.81		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	5865.57							Fee Schedule																													7133.81							Fee Schedule																																															
SYNTH DIST TIBIA RT PLATE 3.5 02.118.202	278	RC	C1713	CPT				Both			7002.45	3151.1	3151.1	6302.21		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	5181.81							Fee Schedule																													6302.21							Fee Schedule																																															
SYNTH DIST TIBIA RT PLATE 3.5 02.118.204	278	RC	C1713	CPT				Both			7084.88	3188.2	3188.2	6376.39		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	5242.81							Fee Schedule																													6376.39							Fee Schedule																																															
SYNTH DIST TIBIA RT PLATE 3.5 02.118.206	278	RC	C1713	CPT				Both			7161.26	3222.57	3222.57	6445.13		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	5299.33							Fee Schedule																													6445.13							Fee Schedule																																															
SYNTH DIST TIBIA RT PLATE 3.5 02.118.208	278	RC	C1713	CPT				Both			7226.63	3251.98	3251.98	6503.97		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	5347.71							Fee Schedule																													6503.97							Fee Schedule																																															
SYNTH DRILL BIT 03.010.060	272	RC						Both			927.15	417.22	417.22	834.44	602.65							Fee Schedule		686.09							Fee Schedule																													834.44							Fee Schedule																																															
SYNTH DRILL BIT 03.010.100	272	RC						Both			739.2	332.64	332.64	665.28	480.48							Fee Schedule		547.01							Fee Schedule																													665.28							Fee Schedule																																															
SYNTH DRILL BIT 03.037.002	270	RC						Both			3725.4	1676.43	1676.43	3352.86	2421.51							Fee Schedule		2756.8							Fee Schedule																													3352.86							Fee Schedule																																															
SYNTH DRILL BIT 03.113.023	270	RC						Both			558.6	251.37	251.37	502.74	363.09							Fee Schedule		413.36							Fee Schedule																													502.74							Fee Schedule																																															
SYNTH DRILL BIT 03.113.024	270	RC						Both			633	284.85	284.85	569.7	411.45							Fee Schedule		468.42							Fee Schedule																													569.7							Fee Schedule																																															
SYNTH DRILL BIT 3.2MM 03.010.103	272	RC						Both			660.45	297.2	297.2	594.41	429.29							Fee Schedule		488.73							Fee Schedule																													594.41							Fee Schedule																																															
SYNTH DRILL BIT 310.63	270	RC						Both			1799	809.55	809.55	1619.1	1169.35							Fee Schedule		1331.26							Fee Schedule																													1619.1							Fee Schedule																																															
SYNTH DRILL BIT 310.632	270	RC						Both			1145.55	515.5	515.5	1031	744.61							Fee Schedule		847.71							Fee Schedule																													1031							Fee Schedule																																															
SYNTH DRILL BIT 310.634	270	RC						Both			1145.55	515.5	515.5	1031	744.61							Fee Schedule		847.71							Fee Schedule																													1031							Fee Schedule																																															
SYNTH DRILL BIT 315.28	272	RC						Both			512	230.4	230.4	460.8	332.8							Fee Schedule		378.88							Fee Schedule																													460.8							Fee Schedule																																															
SYNTH GUIDE PIN #292.622	278	RC						Both			97.65	43.94	43.94	87.89		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	72.26							Fee Schedule																													87.89							Fee Schedule																																															
SYNTH HUMERAL NAIL 04.001.000S	278	RC	C1713	CPT				Both			567	255.15	255.15	510.3		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	419.58							Fee Schedule																													510.3							Fee Schedule																																															
SYNTH HUMERAL NAIL 04.001.438S	278	RC	C1713	CPT				Both			4637.85	2087.03	2087.03	4174.07		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	3432.01							Fee Schedule																													4174.07							Fee Schedule																																															
SYNTH HUMERAL NAIL 462.922S 9.5	278	RC	C1713	CPT				Both			4177.95	1880.08	1880.08	3760.16		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	3091.68							Fee Schedule																													3760.16							Fee Schedule																																															
SYNTH HUMERAL NAIL 462.971S	278	RC	C1713	CPT				Both			4896.15	2203.27	2203.27	4406.54		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	3623.15							Fee Schedule																													4406.54							Fee Schedule																																															
SYNTH HUMERAL NAIL END CAP 462.950S	278	RC	C1713	CPT				Both			497.7	223.97	223.97	447.93		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	368.3							Fee Schedule																													447.93							Fee Schedule																																															
SYNTH KIRSCHNER WIRE #292.26	278	RC						Both			36.75	16.54	16.54	33.08		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	27.2							Fee Schedule																													33.08							Fee Schedule																																															
SYNTH KIRSCHNER WIRE 292.699	278	RC	C1713	CPT				Both			124.95	56.23	56.23	112.46		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	92.46							Fee Schedule																													112.46							Fee Schedule																																															
SYNTH LCP DISTAL RADIUS PLATE #442.512	278	RC	C1713	CPT				Both			1247.4	561.33	561.33	1122.66		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	923.08							Fee Schedule																													1122.66							Fee Schedule																																															
SYNTH LCP DISTAL RADIUS PLATE 04.110.330	278	RC	C1713	CPT				Both			2494.8	1122.66	1122.66	2245.32		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1846.15							Fee Schedule																													2245.32							Fee Schedule																																															
SYNTH LCP DISTAL RADIUS PLATE 04.110.330	278	RC	C1713	CPT				Both			2501.1	1125.5	1125.5	2250.99		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1850.81							Fee Schedule																													2250.99							Fee Schedule																																															
SYNTH LCP DISTAL RADIUS PLATE 04.110.331	278	RC	C1713	CPT				Both			2494.8	1122.66	1122.66	2245.32		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1846.15							Fee Schedule																													2245.32							Fee Schedule																																															
SYNTH LCP DISTAL RADIUS PLATE 04.110.331	278	RC	C1713	CPT				Both			2501.1	1125.5	1125.5	2250.99		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1850.81							Fee Schedule																													2250.99							Fee Schedule																																															
SYNTH LCP DISTAL RADIUS PLATE 04.110.340	278	RC	C1713	CPT				Both			2866.5	1289.93	1289.93	2579.85		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	2121.21							Fee Schedule																													2579.85							Fee Schedule																																															
SYNTH LCP DISTAL RADIUS PLATE 04.110.340	278	RC	C1713	CPT				Both			2608.2	1173.69	1173.69	2347.38		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1930.07							Fee Schedule																													2347.38							Fee Schedule																																															
SYNTH LCP DISTAL RADIUS PLATE 04.110.341	278	RC	C1713	CPT				Both			2948.4	1326.78	1326.78	2653.56		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	2181.82							Fee Schedule																													2653.56							Fee Schedule																																															
SYNTH LCP DISTAL RADIUS PLATE 04.110.341	278	RC	C1713	CPT				Both			2608.2	1173.69	1173.69	2347.38		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1930.07							Fee Schedule																													2347.38							Fee Schedule																																															
SYNTH LCP DISTAL RADIUS PLATE 04.110.350	278	RC	C1713	CPT				Both			2948.4	1326.78	1326.78	2653.56		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	2181.82							Fee Schedule																													2653.56							Fee Schedule																																															
SYNTH LCP DISTAL RADIUS PLATE 04.110.350	278	RC	C1713	CPT				Both			2721.6	1224.72	1224.72	2449.44		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	2013.98							Fee Schedule																													2449.44							Fee Schedule																																															
SYNTH LCP DISTAL RADIUS PLATE 04.110.351	278	RC	C1713	CPT				Both			2948.4	1326.78	1326.78	2653.56		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	2181.82							Fee Schedule																													2653.56							Fee Schedule																																															
SYNTH LCP DISTAL RADIUS PLATE 04.110.351	278	RC	C1713	CPT				Both			2721.6	1224.72	1224.72	2449.44		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	2013.98							Fee Schedule																													2449.44							Fee Schedule																																															
SYNTH LCP DISTAL RADIUS PLATE 04.110.430	278	RC	C1713	CPT				Both			2866.5	1289.93	1289.93	2579.85		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	2121.21							Fee Schedule																													2579.85							Fee Schedule																																															
SYNTH LCP DISTAL RADIUS PLATE 04.110.430	278	RC	C1713	CPT				Both			2778.3	1250.24	1250.24	2500.47		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	2055.94							Fee Schedule																													2500.47							Fee Schedule																																															
SYNTH LCP DISTAL RADIUS PLATE 04.110.431	278	RC	C1713	CPT				Both			2778.3	1250.24	1250.24	2500.47		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	2055.94							Fee Schedule																													2500.47							Fee Schedule																																															
SYNTH LCP DISTAL RADIUS PLATE 04.110.431	278	RC	C1713	CPT				Both			2501.1	1125.5	1125.5	2250.99		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1850.81							Fee Schedule																													2250.99							Fee Schedule																																															
SYNTH LCP DISTAL RADIUS PLATE 04.110.440	278	RC	C1713	CPT				Both			2891.7	1301.27	1301.27	2602.53		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	2139.86							Fee Schedule																													2602.53							Fee Schedule																																															
SYNTH LCP DISTAL RADIUS PLATE 04.110.441	278	RC	C1713	CPT				Both			2869.65	1291.34	1291.34	2582.69		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	2123.54							Fee Schedule																													2582.69							Fee Schedule																																															
SYNTH LCP DISTAL RADIUS PLATE 04.110.441	278	RC	C1713	CPT				Both			2608.2	1173.69	1173.69	2347.38		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1930.07							Fee Schedule																													2347.38							Fee Schedule																																															
SYNTH LCP DISTAL RADIUS PLATE 04.110.450	278	RC	C1713	CPT				Both			2948.4	1326.78	1326.78	2653.56		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	2181.82							Fee Schedule																													2653.56							Fee Schedule																																															
SYNTH LCP DISTAL RADIUS PLATE 04.110.450	278	RC	C1713	CPT				Both			2721.6	1224.72	1224.72	2449.44		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	2013.98							Fee Schedule																													2449.44							Fee Schedule																																															
SYNTH LCP DISTAL RADIUS PLATE 04.110.451	278	RC	C1713	CPT				Both			2948.4	1326.78	1326.78	2653.56		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	2181.82							Fee Schedule																													2653.56							Fee Schedule																																															
SYNTH LCP DISTAL RADIUS PLATE 04.110.451	278	RC	C1713	CPT				Both			2721.6	1224.72	1224.72	2449.44		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	2013.98							Fee Schedule																													2449.44							Fee Schedule																																															
SYNTH LCP DISTAL RADIUS PLATE 04.111.620	278	RC	C1713	CPT				Both			2863.35	1288.51	1288.51	2577.02		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	2118.88							Fee Schedule																													2577.02							Fee Schedule																																															
SYNTH LCP DISTAL RADIUS PLATE 04.111.621	278	RC	C1713	CPT				Both			2863.35	1288.51	1288.51	2577.02		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	2118.88							Fee Schedule																													2577.02							Fee Schedule																																															
SYNTH LCP DISTAL RADIUS PLATE 04.111.630	278	RC	C1713	CPT				Both			3305.4	1487.43	1487.43	2974.86		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	2446							Fee Schedule																													2974.86							Fee Schedule																																															
SYNTH LCP DISTAL RADIUS PLATE 04.111.631	278	RC	C1713	CPT				Both			3305.4	1487.43	1487.43	2974.86		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	2446							Fee Schedule																													2974.86							Fee Schedule																																															
SYNTH LCP DISTAL RADIUS PLATE 04.111.640	278	RC	C1713	CPT				Both			3430.35	1543.66	1543.66	3087.32		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	2538.46							Fee Schedule																													3087.32							Fee Schedule																																															
SYNTH LCP DISTAL RADIUS PLATE 04.111.641	278	RC	C1713	CPT				Both			3090.15	1390.57	1390.57	2781.14		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	2286.71							Fee Schedule																													2781.14							Fee Schedule																																															
SYNTH LCP DISTAL RADIUS PLATE 04.111.720	278	RC	C1713	CPT				Both			3181.5	1431.68	1431.68	2863.35		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	2354.31							Fee Schedule																													2863.35							Fee Schedule																																															
SYNTH LCP DISTAL RADIUS PLATE 04.111.721	278	RC	C1713	CPT				Both			3181.5	1431.68	1431.68	2863.35		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	2354.31							Fee Schedule																													2863.35							Fee Schedule																																															
SYNTH LCP DISTAL RADIUS PLATE 04.111.730	278	RC	C1713	CPT				Both			3307.5	1488.38	1488.38	2976.75		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	2447.55							Fee Schedule																													2976.75							Fee Schedule																																															
SYNTH LCP DISTAL RADIUS PLATE 04.111.731	278	RC	C1713	CPT				Both			3307.5	1488.38	1488.38	2976.75		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	2447.55							Fee Schedule																													2976.75							Fee Schedule																																															
SYNTH LCP DISTAL RADIUS PLATE 04.111.740	278	RC	C1713	CPT				Both			3090.15	1390.57	1390.57	2781.14		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	2286.71							Fee Schedule																													2781.14							Fee Schedule																																															
SYNTH LCP DISTAL RADIUS PLATE 04.111.741	278	RC	C1713	CPT				Both			3090.15	1390.57	1390.57	2781.14		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	2286.71							Fee Schedule																													2781.14							Fee Schedule																																															
SYNTH LCP HOOK PLATE 02.113.103	278	RC	C1713	CPT				Both			1617	727.65	727.65	1455.3		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1196.58							Fee Schedule																													1455.3							Fee Schedule																																															
SYNTH LCP PLATE 236.502	278	RC	C1713	CPT				Both			3056.55	1375.45	1375.45	2750.9		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	2261.85							Fee Schedule																													2750.9							Fee Schedule																																															
SYNTH LCP PLATE 241.151	278	RC	C1713	CPT				Both			1397.55	628.9	628.9	1257.8		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1034.19							Fee Schedule																													1257.8							Fee Schedule																																															
SYNTH LCP PLATE 241.161	278	RC	C1713	CPT				Both			1627.5	732.38	732.38	1464.75		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1204.35							Fee Schedule																													1464.75							Fee Schedule																																															
SYNTH LCP PROXIMAL PLATE 02.124.205	278	RC	C1713	CPT				Both			5439	2447.55	2447.55	4895.1		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	4024.86							Fee Schedule																													4895.1							Fee Schedule																																															
SYNTH LOCKING SCREW 04.005.430S	278	RC	C1713	CPT				Both			873.6	393.12	393.12	786.24		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	646.46							Fee Schedule																													786.24							Fee Schedule																																															
SYNTH LOCKING SCREW 04.005.434S	278	RC	C1713	CPT				Both			1152	518.4	518.4	1036.8		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	852.48							Fee Schedule																													1036.8							Fee Schedule																																															
SYNTH LOCKING SCREW 04.005.540S	278	RC	C1713	CPT				Both			1015.35	456.91	456.91	913.82		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	751.36							Fee Schedule																													913.82							Fee Schedule																																															
SYNTH LOCKING SCREW 04.210.108	278	RC	C1713	CPT				Both			448.35	201.76	201.76	403.52		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	331.78							Fee Schedule																													403.52							Fee Schedule																																															
SYNTH LOCKING SCREW 04.210.110	278	RC	C1713	CPT				Both			448.35	201.76	201.76	403.52		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	331.78							Fee Schedule																													403.52							Fee Schedule																																															
SYNTH LOCKING SCREW 04.210.112	278	RC	C1713	CPT				Both			420	189	189	378		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	310.8							Fee Schedule																													378							Fee Schedule																																															
SYNTH LOCKING SCREW 04.210.114	278	RC	C1713	CPT				Both			451.5	203.18	203.18	406.35		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	334.11							Fee Schedule																													406.35							Fee Schedule																																															
SYNTH LOCKING SCREW 04.210.116	278	RC	C1713	CPT				Both			451.5	203.18	203.18	406.35		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	334.11							Fee Schedule																													406.35							Fee Schedule																																															
SYNTH LOCKING SCREW 04.210.118	278	RC	C1713	CPT				Both			451.5	203.18	203.18	406.35		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	334.11							Fee Schedule																													406.35							Fee Schedule																																															
SYNTH LOCKING SCREW 04.210.120	278	RC	C1713	CPT				Both			451.5	203.18	203.18	406.35		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	334.11							Fee Schedule																													406.35							Fee Schedule																																															
SYNTH LOCKING SCREW 04.210.122	278	RC	C1713	CPT				Both			451.5	203.18	203.18	406.35		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	334.11							Fee Schedule																													406.35							Fee Schedule																																															
SYNTH LOCKING SCREW 04.210.124	278	RC	C1713	CPT				Both			420	189	189	378		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	310.8							Fee Schedule																													378							Fee Schedule																																															
SYNTH LOCKING SCREW 04.210.126	278	RC	C1713	CPT				Both			451.5	203.18	203.18	406.35		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	334.11							Fee Schedule																													406.35							Fee Schedule																																															
SYNTH LOCKING SCREW 04.210.128	278	RC	C1713	CPT				Both			448.35	201.76	201.76	403.52		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	331.78							Fee Schedule																													403.52							Fee Schedule																																															
SYNTH LOCKING SCREW 04.210.130	278	RC	C1713	CPT				Both			448.35	201.76	201.76	403.52		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	331.78							Fee Schedule																													403.52							Fee Schedule																																															
SYNTH LOCKING SCREW 28MM 458.824	278	RC	C1713	CPT				Both			453.6	204.12	204.12	408.24		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	335.66							Fee Schedule																													408.24							Fee Schedule																																															
SYNTH LOCKING SCREW 32MM #04.005.522S	278	RC	C1713	CPT				Both			733.95	330.28	330.28	660.56		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	543.12							Fee Schedule																													660.56							Fee Schedule																																															
SYNTH LOCKING SCREW 38MM #04.005.528S	278	RC	C1713	CPT				Both			788.55	354.85	354.85	709.7		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	583.53							Fee Schedule																													709.7							Fee Schedule																																															
SYNTH LOCKING SCREW 458.926	278	RC	C1713	CPT				Both			453.6	204.12	204.12	408.24		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	335.66							Fee Schedule																													408.24							Fee Schedule																																															
SYNTH LOCKING SCREW 458.928	278	RC	C1713	CPT				Both			453.6	204.12	204.12	408.24		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	335.66							Fee Schedule																													408.24							Fee Schedule																																															
SYNTH LOCKING SCREW 458.930	278	RC	C1713	CPT				Both			453.6	204.12	204.12	408.24		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	335.66							Fee Schedule																													408.24							Fee Schedule																																															
SYNTH LOCKING SCREW 458.938	278	RC	C1713	CPT				Both			453.6	204.12	204.12	408.24		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	335.66							Fee Schedule																													408.24							Fee Schedule																																															
SYNTH LOCKING SCREW 5.0 #04.005.530S	278	RC	C1713	CPT				Both			891	400.95	400.95	801.9		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	659.34							Fee Schedule																													801.9							Fee Schedule																																															
SYNTH LOCKING SCREW 5.0 #04.005.532S	278	RC	C1713	CPT				Both			1015.35	456.91	456.91	913.82		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	751.36							Fee Schedule																													913.82							Fee Schedule																																															
SYNTH LOCKING SCREW 5.0 #04.005.536S	278	RC	C1713	CPT				Both			686.7	309.02	309.02	618.03		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	508.16							Fee Schedule																													618.03							Fee Schedule																																															
SYNTH LOCKING SCREW 5.0 04.005.534S	278	RC	C1713	CPT				Both			1152	518.4	518.4	1036.8		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	852.48							Fee Schedule																													1036.8							Fee Schedule																																															
SYNTH LOCKING SCREW 5.0MM 04.005.516S	278	RC	C1713	CPT				Both			595.35	267.91	267.91	535.82		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	440.56							Fee Schedule																													535.82							Fee Schedule																																															
SYNTH LOCKING SCREW 5.0MM NS 04.005.532	278	RC	C1713	CPT				Both			885	398.25	398.25	796.5		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	654.9							Fee Schedule																													796.5							Fee Schedule																																															
SYNTH LOCKING SCREW 5.0MM NS 04.005.540	278	RC	C1713	CPT				Both			891	400.95	400.95	801.9		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	659.34							Fee Schedule																													801.9							Fee Schedule																																															
SYNTH MEDIAL PLATE 239.958	278	RC	C1713	CPT				Both			5659.5	2546.78	2546.78	5093.55		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	4188.03							Fee Schedule																													5093.55							Fee Schedule																																															
SYNTH MEDIAL PLATE 239.984	278	RC	C1713	CPT				Both			4490.85	2020.88	2020.88	4041.77		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	3323.23							Fee Schedule																													4041.77							Fee Schedule																																															
SYNTH MEDIAL PLATE 239.985	278	RC	C1713	CPT				Both			6342	2853.9	2853.9	5707.8		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	4693.08							Fee Schedule																													5707.8							Fee Schedule																																															
SYNTH MEDIAL PLATE 239.986	278	RC	C1713	CPT				Both			4547.55	2046.4	2046.4	4092.8		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	3365.19							Fee Schedule																													4092.8							Fee Schedule																																															
SYNTH MEDIAL PLATE 239.987	278	RC	C1713	CPT				Both			4547.55	2046.4	2046.4	4092.8		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	3365.19							Fee Schedule																													4092.8							Fee Schedule																																															
SYNTH MEDIAL PLATE 239.988	278	RC	C1713	CPT				Both			4599	2069.55	2069.55	4139.1		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	3403.26							Fee Schedule																													4139.1							Fee Schedule																																															
SYNTH MEDIAL PLATE 239.989	278	RC	C1713	CPT				Both			4599	2069.55	2069.55	4139.1		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	3403.26							Fee Schedule																													4139.1							Fee Schedule																																															
SYNTH MEDIAL PLATE 239.990	278	RC	C1713	CPT				Both			4649.4	2092.23	2092.23	4184.46		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	3440.56							Fee Schedule																													4184.46							Fee Schedule																																															
SYNTH MEDIAL PLATE 239.991	278	RC	C1713	CPT				Both			4649.4	2092.23	2092.23	4184.46		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	3440.56							Fee Schedule																													4184.46							Fee Schedule																																															
SYNTH NORIAN FAST SET PUTTY #SRS.010.FSP	278	RC	C9359	CPT				Both			8278.2	3725.19	3725.19	7450.38		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	6125.87							Fee Schedule																													7450.38							Fee Schedule																																															
SYNTH PIN 5.0 293.740	278	RC	C1713	CPT				Both			391.65	176.24	176.24	352.49		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	289.82							Fee Schedule																													352.49							Fee Schedule																																															
SYNTH PIN CLAMP 390.002	278	RC	C1713	CPT				Both			2038.05	917.12	917.12	1834.25		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1508.16							Fee Schedule																													1834.25							Fee Schedule																																															
SYNTH PLATE #241.921	278	RC	C1713	CPT				Both			6259.05	2816.57	2816.57	5633.15		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	4631.7							Fee Schedule																													5633.15							Fee Schedule																																															
SYNTH PLATE #442.500	278	RC	C1713	CPT				Both			1355.55	610	610	1220		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1003.11							Fee Schedule																													1220							Fee Schedule																																															
SYNTH PLATE #442.502	278	RC	C1713	CPT				Both			1134	510.3	510.3	1020.6		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	839.16							Fee Schedule																													1020.6							Fee Schedule																																															
SYNTH PLATE 442.345	278	RC	C1713	CPT				Both			5142.9	2314.31	2314.31	4628.61		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	3805.75							Fee Schedule																													4628.61							Fee Schedule																																															
SYNTH PLATE 442.503	278	RC	C1713	CPT				Both			1587.6	714.42	714.42	1428.84		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1174.82							Fee Schedule																													1428.84							Fee Schedule																																															
SYNTH RADIUS PLATE 04.110.830	278	RC	C1713	CPT				Both			2863.35	1288.51	1288.51	2577.02		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	2118.88							Fee Schedule																													2577.02							Fee Schedule																																															
SYNTH REAMING ROD W/BALL TIP #351.709S	272	RC	C1713	CPT				Both			462	207.9	207.9	415.8	306.41							Fee Schedule		341.88							Fee Schedule																													415.8							Fee Schedule																																															
SYNTH REDUCTION WIRE 292.41	278	RC	C1713	CPT				Both			972.3	437.54	437.54	875.07		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	719.5							Fee Schedule																													875.07							Fee Schedule																																															
SYNTH ROD CLAMP 390.007	278	RC	C1713	CPT				Both			2432.85	1094.78	1094.78	2189.57		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1800.31							Fee Schedule																													2189.57							Fee Schedule																																															
SYNTH SCREW 218.045	278	RC	C1713	CPT				Both			126	56.7	56.7	113.4		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	93.24							Fee Schedule																													113.4							Fee Schedule																																															
SYNTH SHANE SCREW 294.785	278	RC	C1713	CPT				Both			567	255.15	255.15	510.3		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	419.58							Fee Schedule																													510.3							Fee Schedule																																															
SYNTH SHORT NAIL 04.037.142S	278	RC	C1713	CPT				Both			7611	3424.95	3424.95	6849.9		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	5632.14							Fee Schedule																													6849.9							Fee Schedule																																															
SYNTH SHORT NAIL 04.037.153S	278	RC	C1713	CPT				Both			10849	4882.05	4882.05	9764.1		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	8028.26							Fee Schedule																													9764.1							Fee Schedule																																															
SYNTH SHORT NAIL 04.037.154S	278	RC	C1713	CPT				Both			11484	5167.8	5167.8	10335.6		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	8498.16							Fee Schedule																													10335.6							Fee Schedule																																															
SYNTH SHORT NAIL 04.037.155S	278	RC	C1713	CPT				Both			10849	4882.05	4882.05	9764.1		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	8028.26							Fee Schedule																													9764.1							Fee Schedule																																															
SYNTH SHORT NAIL 04.037.156S	278	RC	C1713	CPT				Both			10849	4882.05	4882.05	9764.1		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	8028.26							Fee Schedule																													9764.1							Fee Schedule																																															
SYNTH SHORT NAIL 04.037.157S	278	RC	C1713	CPT				Both			10144.05	4564.82	4564.82	9129.65		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	7506.6							Fee Schedule																													9129.65							Fee Schedule																																															
SYNTH SHORT NAIL 04.037.158S	278	RC	C1713	CPT				Both			10144.05	4564.82	4564.82	9129.65		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	7506.6							Fee Schedule																													9129.65							Fee Schedule																																															
SYNTH SHORT NAIL 04.037.159S	278	RC	C1713	CPT				Both			11391	5125.95	5125.95	10251.9		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	8429.34							Fee Schedule																													10251.9							Fee Schedule																																															
SYNTH SPIRAL BLADE 36MM #462.636	278	RC	C1713	CPT				Both			1197	538.65	538.65	1077.3		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	885.78							Fee Schedule																													1077.3							Fee Schedule																																															
SYNTH SPIRAL BLADE 42MM 462.642	278	RC	C1713	CPT				Both			1413.3	635.99	635.99	1271.97		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1045.84							Fee Schedule																													1271.97							Fee Schedule																																															
SYNTH TFNA NAIL 04.037.160S	278	RC	C1713	CPT				Both			10144.05	4564.82	4564.82	9129.65		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	7506.6							Fee Schedule																													9129.65							Fee Schedule																																															
SYNTH TFNA NAIL 04.037.161S	278	RC	C1713	CPT				Both			10144.05	4564.82	4564.82	9129.65		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	7506.6							Fee Schedule																													9129.65							Fee Schedule																																															
SYNTH TFNA NAIL 04.037.165S	278	RC	C1713	CPT				Both			11391	5125.95	5125.95	10251.9		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	8429.34							Fee Schedule																													10251.9							Fee Schedule																																															
SYNTH TFNA NAIL 04.037.242S	278	RC	C1713	CPT				Both			8199	3689.55	3689.55	7379.1		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	6067.26							Fee Schedule																													7379.1							Fee Schedule																																															
SYNTH TI CAP TROCHAN FIX NAILS 456.312	278	RC	C1713	CPT				Both			320.25	144.11	144.11	288.23		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	236.99							Fee Schedule																													288.23							Fee Schedule																																															
SYNTH TI LOCKING  BOLT 36MM 459.63S	278	RC	C1713	CPT				Both			443.1	199.4	199.4	398.79		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	327.89							Fee Schedule																													398.79							Fee Schedule																																															
SYNTH TIBIA PLATE 238.707 NEW#02.112.523	278	RC	C1713	CPT				Both			10134	4560.3	4560.3	9120.6		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	7499.16							Fee Schedule																													9120.6							Fee Schedule																																															
SYNTH TIBIA PLATE 238.710 NEW#02.112.530	278	RC	C1713	CPT				Both			6532.05	2939.42	2939.42	5878.85		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	4833.72							Fee Schedule																													5878.85							Fee Schedule																																															
SYNTH TIBIAL NAIL #04.004.446S	278	RC	C1713	CPT				Both			4564.35	2053.96	2053.96	4107.92		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	3377.62							Fee Schedule																													4107.92							Fee Schedule																																															
SYNTH TIBIAL NAIL #04.004.449S	278	RC	C1713	CPT				Both			3969	1786.05	1786.05	3572.1		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	2937.06							Fee Schedule																													3572.1							Fee Schedule																																															
SYNTH TIBIAL NAIL 04.004.246S	278	RC	C1713	CPT				Both			4212.6	1895.67	1895.67	3791.34		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	3117.32							Fee Schedule																													3791.34							Fee Schedule																																															
SYNTH TIBIAL NAIL 10MM #04.004.443S	278	RC	C1713	CPT				Both			4536	2041.2	2041.2	4082.4		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	3356.64							Fee Schedule																													4082.4							Fee Schedule																																															
SYNTH VOLAR PLATE 442.491	278	RC	C1713	CPT				Both			2731.05	1228.97	1228.97	2457.95		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	2020.98							Fee Schedule																													2457.95							Fee Schedule																																															
SYNTH WASHER #219.89	278	RC	C1713	CPT				Both			340.2	153.09	153.09	306.18		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	251.75							Fee Schedule																													306.18							Fee Schedule																																															
SYNTH.  TIBIA PLATE 02.127.221	278	RC	C1713	CPT				Both			5856.9	2635.61	2635.61	5271.21		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	4334.11							Fee Schedule																													5271.21							Fee Schedule																																															
SYNTH.  TIBIA PLATE 3.5MM 02.127.241	278	RC	C1713	CPT				Both			6942.6	3124.17	3124.17	6248.34		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	5137.52							Fee Schedule																													6248.34							Fee Schedule																																															
SYNTH. .76 DRILL BIT #316.286	272	RC						Both			302.4	136.08	136.08	272.16	196.56							Fee Schedule		223.78							Fee Schedule																													272.16							Fee Schedule																																															
SYNTH. .76 DRILL BIT #316.288	272	RC						Both			302.4	136.08	136.08	272.16	196.56							Fee Schedule		223.78							Fee Schedule																													272.16							Fee Schedule																																															
SYNTH. .76 DRILL BIT #316.290	272	RC						Both			302.4	136.08	136.08	272.16	196.56							Fee Schedule		223.78							Fee Schedule																													272.16							Fee Schedule																																															
SYNTH. .76 DRILL BIT #316.292	272	RC						Both			302.4	136.08	136.08	272.16	196.56							Fee Schedule		223.78							Fee Schedule																													272.16							Fee Schedule																																															
SYNTH. .76 DRILL BIT #316.294	272	RC						Both			302.4	136.08	136.08	272.16	196.56							Fee Schedule		223.78							Fee Schedule																													272.16							Fee Schedule																																															
SYNTH. 1.8MM 310.509	278	RC	C1713	CPT				Both			507.15	228.22	228.22	456.44		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	375.29							Fee Schedule																													456.44							Fee Schedule																																															
SYNTH. 11MM CARB.FIB.ROD 100MM  394.80	278	RC	C1713	CPT				Both			947.1	426.2	426.2	852.39		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	700.85							Fee Schedule																													852.39							Fee Schedule																																															
SYNTH. 11MM CARB.FIB.ROD 150MM 394.82	278	RC	C1713	CPT				Both			765.45	344.45	344.45	688.91		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	566.43							Fee Schedule																													688.91							Fee Schedule																																															
SYNTH. 11MM CARB.FIB.ROD 200MM  394.83	278	RC	C1713	CPT				Both			1088.85	489.98	489.98	979.97		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	805.75							Fee Schedule																													979.97							Fee Schedule																																															
SYNTH. 11MM CARB.FIB.ROD 350MM  394.86	278	RC	C1713	CPT				Both			1190.7	535.82	535.82	1071.63		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	881.12							Fee Schedule																													1071.63							Fee Schedule																																															
SYNTH. 11MM CARB.FIB.ROD 400MM  394.87	278	RC	C1713	CPT				Both			939.75	422.89	422.89	845.78		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	695.42							Fee Schedule																													845.78							Fee Schedule																																															
SYNTH. 135 BARREL 281.14	278	RC	C1713	CPT				Both			1114.05	501.32	501.32	1002.65		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	824.4							Fee Schedule																													1002.65							Fee Schedule																																															
SYNTH. 14 HOLE PLATE # 223.641	278	RC	C1713	CPT				Both			2106.3	947.84	947.84	1895.67		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1558.66							Fee Schedule																													1895.67							Fee Schedule																																															
SYNTH. 2.4 MODULAR HAND #401.512	278	RC	C1713	CPT				Both			198.45	89.3	89.3	178.61		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	146.85							Fee Schedule																													178.61							Fee Schedule																																															
SYNTH. 2.4 MODULAR HAND #401.516	278	RC	C1713	CPT				Both			198.45	89.3	89.3	178.61		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	146.85							Fee Schedule																													178.61							Fee Schedule																																															
SYNTH. 2.4 MODULAR HAND #401.518	278	RC	C1713	CPT				Both			198.45	89.3	89.3	178.61		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	146.85							Fee Schedule																													178.61							Fee Schedule																																															
SYNTH. 2.4 SCREW 412.808	278	RC	C1713	CPT				Both			376.95	169.63	169.63	339.26		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	278.94							Fee Schedule																													339.26							Fee Schedule																																															
SYNTH. 3.2 calib. drill bit #315.330	270	RC						Both			396.9	178.61	178.61	357.21	257.99							Fee Schedule		293.71							Fee Schedule																													357.21							Fee Schedule																																															
SYNTH. 3.5 LCP PLATE 7 HOLE 223.571	278	RC	C1713	CPT				Both			1451.1	653	653	1305.99		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1073.81							Fee Schedule																													1305.99							Fee Schedule																																															
SYNTH. 3.5mm LCP ANTERLATERAL PL 241.441	278	RC	C1713	CPT				Both			4840.5	2178.23	2178.23	4356.45		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	3581.97							Fee Schedule																													4356.45							Fee Schedule																																															
SYNTH. 3.5MM LCP ANTEROLAT DST TIB PL 5	278	RC	C1713	CPT				Both			4851	2182.95	2182.95	4365.9		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	3589.74							Fee Schedule																													4365.9							Fee Schedule																																															
SYNTH. 36MMLOCKING SCREW # 04.005.526S	278	RC	C1713	CPT				Both			1015.35	456.91	456.91	913.82		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	751.36							Fee Schedule																													913.82							Fee Schedule																																															
SYNTH. 3-HOLE PLATE 02.114.513	278	RC	C1713	CPT				Both			1885.8	848.61	848.61	1697.22		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1395.49							Fee Schedule																													1697.22							Fee Schedule																																															
SYNTH. 4.0 3FLUTED DRILL BIT #357.407	272	RC	C1713	CPT				Both			930.3	418.64	306.41	837.27	306.41							Fee Schedule		688.42							Fee Schedule																													837.27							Fee Schedule																																															
SYNTH. 4.5 CORTEX SCREW 214.822	278	RC	C1713	CPT				Both			94.5	42.53	42.53	85.05		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	69.93							Fee Schedule																													85.05							Fee Schedule																																															
SYNTH. 4.5 S/T SCREW 38MM 214.838	278	RC	C1713	CPT				Both			47.25	21.26	21.26	42.53		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	34.97							Fee Schedule																													42.53							Fee Schedule																																															
SYNTH. 4.5 S/T SCREW 40MM 214.840	278	RC	C1713	CPT				Both			87.15	39.22	39.22	78.44		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	64.49							Fee Schedule																													78.44							Fee Schedule																																															
SYNTH. 4.5 S/T SCREW 50MM 214.850	278	RC	C1713	CPT				Both			47.25	21.26	21.26	42.53		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	34.97							Fee Schedule																													42.53							Fee Schedule																																															
SYNTH. 4.5 S/T SCREW 52MM 214.852	278	RC	C1713	CPT				Both			47.25	21.26	21.26	42.53		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	34.97							Fee Schedule																													42.53							Fee Schedule																																															
SYNTH. 4.5 S/T SCREW 54MM 214.854	278	RC	C1713	CPT				Both			47.25	21.26	21.26	42.53		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	34.97							Fee Schedule																													42.53							Fee Schedule																																															
SYNTH. 4.5 S/T SCREW 66MM 214.866	278	RC	C1713	CPT				Both			76.65	34.49	34.49	68.99		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	56.72							Fee Schedule																													68.99							Fee Schedule																																															
SYNTH. 5.0 SCREW #458.938	278	RC	C1713	CPT				Both			808.5	363.83	363.83	727.65		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	598.29							Fee Schedule																													727.65							Fee Schedule																																															
SYNTH. 5.0 TI LOCK SCREW #458.936S	278	RC	C1713	CPT				Both			454.65	204.59	204.59	409.19		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	336.44							Fee Schedule																													409.19							Fee Schedule																																															
SYNTH. 6.0 LOCK SCREW TI #450.864	278	RC	C1713	CPT				Both			453.6	204.12	204.12	408.24		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	335.66							Fee Schedule																													408.24							Fee Schedule																																															
SYNTH. 6.0 LOCK SCREW TI #450.869	278	RC	C1713	CPT				Both			453.6	204.12	204.12	408.24		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	335.66							Fee Schedule																													408.24							Fee Schedule																																															
SYNTH. 6.0 LOCKING SCREW # 04.005.542S	278	RC	C1713	CPT				Both			847.35	381.31	381.31	762.62		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	627.04							Fee Schedule																													762.62							Fee Schedule																																															
SYNTH. 9 HOLE PLATE 223.591	278	RC	C1713	CPT				Both			2214.45	996.5	996.5	1993.01		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1638.69							Fee Schedule																													1993.01							Fee Schedule																																															
SYNTH. AIMING ARM 357.366	272	RC	C1713	CPT				Both			3617.25	1627.76	306.41	3255.53	306.41							Fee Schedule		2676.77							Fee Schedule																													3255.53							Fee Schedule																																															
SYNTH. AIMING ARM KNOB 03.019.030	272	RC	C1713	CPT				Both			1517.25	682.76	306.41	1365.53	306.41							Fee Schedule		1122.77							Fee Schedule																													1365.53							Fee Schedule																																															
SYNTH. BLADE GUIDE SLEEVE 357.369	272	RC						Both			3746.4	1685.88	1685.88	3371.76	2435.16							Fee Schedule		2772.34							Fee Schedule																													3371.76							Fee Schedule																																															
SYNTH. CALCANEAL PLATE 02.211.405	278	RC	C1713	CPT				Both			4147.5	1866.38	1866.38	3732.75		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	3069.15							Fee Schedule																													3732.75							Fee Schedule																																															
SYNTH. CANC.  SCREW #216.030	278	RC	C1713	CPT				Both			174	78.3	78.3	156.6		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	128.76							Fee Schedule																													156.6							Fee Schedule																																															
SYNTH. CANC.  SCREW #216.035	278	RC	C1713	CPT				Both			175.35	78.91	78.91	157.82		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	129.76							Fee Schedule																													157.82							Fee Schedule																																															
SYNTH. CANC.  SCREW #216.040	278	RC	C1713	CPT				Both			85.05	38.27	38.27	76.55		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	62.94							Fee Schedule																													76.55							Fee Schedule																																															
SYNTH. CANC.  SCREW #216.045	278	RC	C1713	CPT				Both			85.05	38.27	38.27	76.55		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	62.94							Fee Schedule																													76.55							Fee Schedule																																															
SYNTH. CANC.  SCREW #216.050	278	RC	C1713	CPT				Both			85.05	38.27	38.27	76.55		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	62.94							Fee Schedule																													76.55							Fee Schedule																																															
SYNTH. CANC.  SCREW #216.055	278	RC	C1713	CPT				Both			124.95	56.23	56.23	112.46		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	92.46							Fee Schedule																													112.46							Fee Schedule																																															
SYNTH. CANC.  SCREW #216.060	278	RC	C1713	CPT				Both			85.05	38.27	38.27	76.55		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	62.94							Fee Schedule																													76.55							Fee Schedule																																															
SYNTH. CANC.  SCREW #216.065	278	RC	C1713	CPT				Both			85.05	38.27	38.27	76.55		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	62.94							Fee Schedule																													76.55							Fee Schedule																																															
SYNTH. CANC.  SCREW #216.070	278	RC	C1713	CPT				Both			85.05	38.27	38.27	76.55		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	62.94							Fee Schedule																													76.55							Fee Schedule																																															
SYNTH. CANC.  SCREW #216.075	278	RC	C1713	CPT				Both			85.05	38.27	38.27	76.55		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	62.94							Fee Schedule																													76.55							Fee Schedule																																															
SYNTH. CANC.  SCREW #216.080	278	RC	C1713	CPT				Both			85.05	38.27	38.27	76.55		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	62.94							Fee Schedule																													76.55							Fee Schedule																																															
SYNTH. CANC.  SCREW #216.085	278	RC	C1713	CPT				Both			91.35	41.11	41.11	82.22		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	67.6							Fee Schedule																													82.22							Fee Schedule																																															
SYNTH. CANC.  SCREW #216.090	278	RC	C1713	CPT				Both			91.35	41.11	41.11	82.22		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	67.6							Fee Schedule																													82.22							Fee Schedule																																															
SYNTH. CANC.  SCREW #216.095	278	RC	C1713	CPT				Both			91.35	41.11	41.11	82.22		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	67.6							Fee Schedule																													82.22							Fee Schedule																																															
SYNTH. CANC.  SCREW #216.100	278	RC	C1713	CPT				Both			91.35	41.11	41.11	82.22		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	67.6							Fee Schedule																													82.22							Fee Schedule																																															
SYNTH. CANC.  SCREW #216.105	278	RC	C1713	CPT				Both			91.35	41.11	41.11	82.22		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	67.6							Fee Schedule																													82.22							Fee Schedule																																															
SYNTH. CANC.  SCREW #216.110	278	RC	C1713	CPT				Both			91.35	41.11	41.11	82.22		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	67.6							Fee Schedule																													82.22							Fee Schedule																																															
SYNTH. CANC.  SCREW #216.115	278	RC	C1713	CPT				Both			113.4	51.03	51.03	102.06		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	83.92							Fee Schedule																													102.06							Fee Schedule																																															
SYNTH. CANC.  SCREW #216.120	278	RC	C1713	CPT				Both			113.4	51.03	51.03	102.06		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	83.92							Fee Schedule																													102.06							Fee Schedule																																															
SYNTH. CANC.  SCREW #216.125	278	RC	C1713	CPT				Both			113.4	51.03	51.03	102.06		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	83.92							Fee Schedule																													102.06							Fee Schedule																																															
SYNTH. CANC.  SCREW #216.130	278	RC	C1713	CPT				Both			113.4	51.03	51.03	102.06		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	83.92							Fee Schedule																													102.06							Fee Schedule																																															
SYNTH. CANC.  SCREW #216.135	278	RC	C1713	CPT				Both			113.4	51.03	51.03	102.06		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	83.92							Fee Schedule																													102.06							Fee Schedule																																															
SYNTH. CANC.  SCREW #216.140	278	RC	C1713	CPT				Both			113.4	51.03	51.03	102.06		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	83.92							Fee Schedule																													102.06							Fee Schedule																																															
SYNTH. CANC.  SCREW #216.145	278	RC	C1713	CPT				Both			85.05	38.27	38.27	76.55		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	62.94							Fee Schedule																													76.55							Fee Schedule																																															
SYNTH. CANC.  SCREW #216.150	278	RC	C1713	CPT				Both			85.05	38.27	38.27	76.55		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	62.94							Fee Schedule																													76.55							Fee Schedule																																															
SYNTH. CANC.  SCREW #217.045	278	RC	C1713	CPT				Both			175.35	78.91	78.91	157.82		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	129.76							Fee Schedule																													157.82							Fee Schedule																																															
SYNTH. CANC.  SCREW #217.050	278	RC	C1713	CPT				Both			121.8	54.81	54.81	109.62		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	90.13							Fee Schedule																													109.62							Fee Schedule																																															
SYNTH. CANC.  SCREW #217.055	278	RC	C1713	CPT				Both			121.8	54.81	54.81	109.62		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	90.13							Fee Schedule																													109.62							Fee Schedule																																															
SYNTH. CANC.  SCREW #217.060	278	RC	C1713	CPT				Both			113.4	51.03	51.03	102.06		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	83.92							Fee Schedule																													102.06							Fee Schedule																																															
SYNTH. CANC.  SCREW #217.065	278	RC	C1713	CPT				Both			85.05	38.27	38.27	76.55		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	62.94							Fee Schedule																													76.55							Fee Schedule																																															
SYNTH. CANC.  SCREW #217.070	278	RC	C1713	CPT				Both			124.95	56.23	56.23	112.46		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	92.46							Fee Schedule																													112.46							Fee Schedule																																															
SYNTH. CANC.  SCREW #217.075	278	RC	C1713	CPT				Both			85.05	38.27	38.27	76.55		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	62.94							Fee Schedule																													76.55							Fee Schedule																																															
SYNTH. CANC.  SCREW #217.080	278	RC	C1713	CPT				Both			85.05	38.27	38.27	76.55		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	62.94							Fee Schedule																													76.55							Fee Schedule																																															
SYNTH. CANC.  SCREW #217.085	278	RC	C1713	CPT				Both			96.6	43.47	43.47	86.94		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	71.48							Fee Schedule																													86.94							Fee Schedule																																															
SYNTH. CANC.  SCREW #217.090	278	RC	C1713	CPT				Both			96.6	43.47	43.47	86.94		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	71.48							Fee Schedule																													86.94							Fee Schedule																																															
SYNTH. CANC.  SCREW #217.095	278	RC	C1713	CPT				Both			96.6	43.47	43.47	86.94		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	71.48							Fee Schedule																													86.94							Fee Schedule																																															
SYNTH. CANC.  SCREW #217.100	278	RC	C1713	CPT				Both			96.6	43.47	43.47	86.94		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	71.48							Fee Schedule																													86.94							Fee Schedule																																															
SYNTH. CANC.  SCREW #217.105	278	RC	C1713	CPT				Both			136.5	61.43	61.43	122.85		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	101.01							Fee Schedule																													122.85							Fee Schedule																																															
SYNTH. CANC.  SCREW #217.110	278	RC	C1713	CPT				Both			96.6	43.47	43.47	86.94		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	71.48							Fee Schedule																													86.94							Fee Schedule																																															
SYNTH. CANC.  SCREW #218.025	278	RC	C1713	CPT				Both			85.05	38.27	38.27	76.55		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	62.94							Fee Schedule																													76.55							Fee Schedule																																															
SYNTH. CANC.  SCREW #218.030	278	RC	C1713	CPT				Both			175.35	78.91	78.91	157.82		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	129.76							Fee Schedule																													157.82							Fee Schedule																																															
SYNTH. CANC.  SCREW #218.035	278	RC	C1713	CPT				Both			85.05	38.27	38.27	76.55		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	62.94							Fee Schedule																													76.55							Fee Schedule																																															
SYNTH. CANC.  SCREW #218.040	278	RC	C1713	CPT				Both			124.95	56.23	56.23	112.46		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	92.46							Fee Schedule																													112.46							Fee Schedule																																															
SYNTH. CANC.  SCREW #218.050	278	RC	C1713	CPT				Both			124.95	56.23	56.23	112.46		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	92.46							Fee Schedule																													112.46							Fee Schedule																																															
SYNTH. CANC.  SCREW #218.055	278	RC	C1713	CPT				Both			124.95	56.23	56.23	112.46		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	92.46							Fee Schedule																													112.46							Fee Schedule																																															
SYNTH. CANC.  SCREW #218.060	278	RC	C1713	CPT				Both			124.95	56.23	56.23	112.46		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	92.46							Fee Schedule																													112.46							Fee Schedule																																															
SYNTH. CAP FOR TIBIAL NAIL #04.004.011S	278	RC	C1713	CPT				Both			726.6	326.97	326.97	653.94		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	537.68							Fee Schedule																													653.94							Fee Schedule																																															
SYNTH. CLAVICLE HOOK PLATE 241.073S	278	RC	C1713	CPT				Both			2315.25	1041.86	1041.86	2083.73		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1713.29							Fee Schedule																													2083.73							Fee Schedule																																															
SYNTH. COMPRESSION NUT 357.371	278	RC	C1713	CPT				Both			467.25	210.26	210.26	420.53		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	345.77							Fee Schedule																													420.53							Fee Schedule																																															
SYNTH. COMPRESSION SCREW 02.226.020	278	RC	C1713	CPT				Both			1151.85	518.33	518.33	1036.67		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	852.37							Fee Schedule																													1036.67							Fee Schedule																																															
SYNTH. COMPRESSION SCREW 02.226.021	278	RC	C1713	CPT				Both			1151.85	518.33	518.33	1036.67		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	852.37							Fee Schedule																													1036.67							Fee Schedule																																															
SYNTH. CONDYLAR PLATE 02.114.514	278	RC	C1713	CPT				Both			2291.1	1031	1031	2061.99		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1695.41							Fee Schedule																													2061.99							Fee Schedule																																															
SYNTH. CONICAL EXTRACT. SCREW 387.34	278	RC	C1713	CPT				Both			1026.9	462.11	462.11	924.21		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	759.91							Fee Schedule																													924.21							Fee Schedule																																															
SYNTH. CONNECTING SCREW 03.010.474	278	RC	C1713	CPT				Both			745.5	335.48	335.48	670.95		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	551.67							Fee Schedule																													670.95							Fee Schedule																																															
SYNTH. CORTEX SCREW #214.014	278	RC	C1713	CPT				Both			46.2	20.79	20.79	41.58		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	34.19							Fee Schedule																													41.58							Fee Schedule																																															
SYNTH. CORTEX SCREW #214.016	278	RC	C1713	CPT				Both			46.2	20.79	20.79	41.58		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	34.19							Fee Schedule																													41.58							Fee Schedule																																															
SYNTH. CORTEX SCREW #214.018	278	RC	C1713	CPT				Both			46.2	20.79	20.79	41.58		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	34.19							Fee Schedule																													41.58							Fee Schedule																																															
SYNTH. CORTEX SCREW #214.020	278	RC	C1713	CPT				Both			46.2	20.79	20.79	41.58		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	34.19							Fee Schedule																													41.58							Fee Schedule																																															
SYNTH. CORTEX SCREW #214.022	278	RC	C1713	CPT				Both			46.2	20.79	20.79	41.58		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	34.19							Fee Schedule																													41.58							Fee Schedule																																															
SYNTH. CORTEX SCREW #214.024	278	RC	C1713	CPT				Both			56.7	25.52	25.52	51.03		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	41.96							Fee Schedule																													51.03							Fee Schedule																																															
SYNTH. CORTEX SCREW #214.026	278	RC	C1713	CPT				Both			56.7	25.52	25.52	51.03		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	41.96							Fee Schedule																													51.03							Fee Schedule																																															
SYNTH. CORTEX SCREW #214.028	278	RC	C1713	CPT				Both			56.7	25.52	25.52	51.03		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	41.96							Fee Schedule																													51.03							Fee Schedule																																															
SYNTH. CORTEX SCREW #214.030	278	RC	C1713	CPT				Both			46.2	20.79	20.79	41.58		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	34.19							Fee Schedule																													41.58							Fee Schedule																																															
SYNTH. CORTEX SCREW #214.032	278	RC	C1713	CPT				Both			46.2	20.79	20.79	41.58		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	34.19							Fee Schedule																													41.58							Fee Schedule																																															
SYNTH. CORTEX SCREW #214.034	278	RC	C1713	CPT				Both			46.2	20.79	20.79	41.58		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	34.19							Fee Schedule																													41.58							Fee Schedule																																															
SYNTH. CORTEX SCREW #214.036	278	RC	C1713	CPT				Both			46.2	20.79	20.79	41.58		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	34.19							Fee Schedule																													41.58							Fee Schedule																																															
SYNTH. CORTEX SCREW #214.038	278	RC	C1713	CPT				Both			46.2	20.79	20.79	41.58		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	34.19							Fee Schedule																													41.58							Fee Schedule																																															
SYNTH. CORTEX SCREW #214.040	278	RC	C1713	CPT				Both			46.2	20.79	20.79	41.58		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	34.19							Fee Schedule																													41.58							Fee Schedule																																															
SYNTH. CORTEX SCREW #214.042	278	RC	C1713	CPT				Both			46.2	20.79	20.79	41.58		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	34.19							Fee Schedule																													41.58							Fee Schedule																																															
SYNTH. CORTEX SCREW #214.044	278	RC	C1713	CPT				Both			46.2	20.79	20.79	41.58		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	34.19							Fee Schedule																													41.58							Fee Schedule																																															
SYNTH. CORTEX SCREW #214.046	278	RC	C1713	CPT				Both			46.2	20.79	20.79	41.58		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	34.19							Fee Schedule																													41.58							Fee Schedule																																															
SYNTH. CORTEX SCREW #214.048	278	RC	C1713	CPT				Both			46.2	20.79	20.79	41.58		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	34.19							Fee Schedule																													41.58							Fee Schedule																																															
SYNTH. CORTEX SCREW #214.050	278	RC	C1713	CPT				Both			46.2	20.79	20.79	41.58		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	34.19							Fee Schedule																													41.58							Fee Schedule																																															
SYNTH. CORTEX SCREW #214.052	278	RC	C1713	CPT				Both			46.2	20.79	20.79	41.58		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	34.19							Fee Schedule																													41.58							Fee Schedule																																															
SYNTH. CORTEX SCREW #214.054	278	RC	C1713	CPT				Both			46.2	20.79	20.79	41.58		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	34.19							Fee Schedule																													41.58							Fee Schedule																																															
SYNTH. CORTEX SCREW #214.056	278	RC	C1713	CPT				Both			46.2	20.79	20.79	41.58		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	34.19							Fee Schedule																													41.58							Fee Schedule																																															
SYNTH. CORTEX SCREW #214.058	278	RC	C1713	CPT				Both			46.2	20.79	20.79	41.58		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	34.19							Fee Schedule																													41.58							Fee Schedule																																															
SYNTH. CORTEX SCREW #214.060	278	RC	C1713	CPT				Both			46.2	20.79	20.79	41.58		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	34.19							Fee Schedule																													41.58							Fee Schedule																																															
SYNTH. CORTEX SCREW #214.062	278	RC	C1713	CPT				Both			46.2	20.79	20.79	41.58		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	34.19							Fee Schedule																													41.58							Fee Schedule																																															
SYNTH. CORTEX SCREW #214.064	278	RC	C1713	CPT				Both			46.2	20.79	20.79	41.58		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	34.19							Fee Schedule																													41.58							Fee Schedule																																															
SYNTH. CORTEX SCREW #214.066	278	RC	C1713	CPT				Both			46.2	20.79	20.79	41.58		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	34.19							Fee Schedule																													41.58							Fee Schedule																																															
SYNTH. CORTEX SCREW #214.068	278	RC	C1713	CPT				Both			46.2	20.79	20.79	41.58		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	34.19							Fee Schedule																													41.58							Fee Schedule																																															
SYNTH. CORTEX SCREW #214.070	278	RC	C1713	CPT				Both			46.2	20.79	20.79	41.58		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	34.19							Fee Schedule																													41.58							Fee Schedule																																															
SYNTH. CORTEX SCREW #214.072	278	RC	C1713	CPT				Both			46.2	20.79	20.79	41.58		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	34.19							Fee Schedule																													41.58							Fee Schedule																																															
SYNTH. CORTEX SCREW #214.076	278	RC	C1713	CPT				Both			74.55	33.55	33.55	67.1		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	55.17							Fee Schedule																													67.1							Fee Schedule																																															
SYNTH. CORTEX SCREW #214.080	278	RC	C1713	CPT				Both			74.55	33.55	33.55	67.1		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	55.17							Fee Schedule																													67.1							Fee Schedule																																															
SYNTH. CORTEX SCREW #214.085	278	RC	C1713	CPT				Both			74.55	33.55	33.55	67.1		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	55.17							Fee Schedule																													67.1							Fee Schedule																																															
SYNTH. CORTEX SCREW #214.860	278	RC	C1713	CPT				Both			84	37.8	37.8	75.6		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	62.16							Fee Schedule																													75.6							Fee Schedule																																															
SYNTH. CORTEX SCREW 02.214.110	278	RC	C1713	CPT				Both			189	85.05	85.05	170.1		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	139.86							Fee Schedule																													170.1							Fee Schedule																																															
SYNTH. CORTEX SCREW 02.214.111	278	RC	C1713	CPT				Both			189	85.05	85.05	170.1		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	139.86							Fee Schedule																													170.1							Fee Schedule																																															
SYNTH. CORTEX SCREW 02.214.112	278	RC	C1713	CPT				Both			189	85.05	85.05	170.1		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	139.86							Fee Schedule																													170.1							Fee Schedule																																															
SYNTH. CORTEX SCREW 02.214.116	278	RC	C1713	CPT				Both			189	85.05	85.05	170.1		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	139.86							Fee Schedule																													170.1							Fee Schedule																																															
SYNTH. CORTEX SCREW 10MM #402.870	278	RC	C1713	CPT				Both			124.95	56.23	56.23	112.46		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	92.46							Fee Schedule																													112.46							Fee Schedule																																															
SYNTH. CORTEX SCREW 18MM #402.878	278	RC	C1713	CPT				Both			126	56.7	56.7	113.4		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	93.24							Fee Schedule																													113.4							Fee Schedule																																															
SYNTH. CORTEX SCREW 202.874	278	RC	C1713	CPT				Both			127.05	57.17	57.17	114.35		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	94.02							Fee Schedule																													114.35							Fee Schedule																																															
SYNTH. CORTEX SCREW 20MM #402.880	278	RC	C1713	CPT				Both			193.2	86.94	86.94	173.88		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	142.97							Fee Schedule																													173.88							Fee Schedule																																															
SYNTH. CORTEX SCREW 26MM #402.886	278	RC	C1713	CPT				Both			187.95	84.58	84.58	169.16		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	139.08							Fee Schedule																													169.16							Fee Schedule																																															
SYNTH. CORTEX SCREW 28MM #402.888	278	RC	C1713	CPT				Both			181.65	81.74	81.74	163.49		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	134.42							Fee Schedule																													163.49							Fee Schedule																																															
SYNTH. CORTEX SCREW 30MM #402.890	278	RC	C1713	CPT				Both			193.2	86.94	86.94	173.88		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	142.97							Fee Schedule																													173.88							Fee Schedule																																															
SYNTH. CORTEX SCREW 412.806	278	RC	C1713	CPT				Both			388.5	174.83	174.83	349.65		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	287.49							Fee Schedule																													349.65							Fee Schedule																																															
SYNTH. DCS PLATE 281.98	278	RC	C1713	CPT				Both			1667.4	750.33	750.33	1500.66		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1233.88							Fee Schedule																													1500.66							Fee Schedule																																															
SYNTH. DHC/DCP PLATE #281.040	278	RC	C1713	CPT				Both			1722	774.9	774.9	1549.8		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1274.28							Fee Schedule																													1549.8							Fee Schedule																																															
SYNTH. DRILL BIT 2.0 #310.19	272	RC						Both			300.3	135.14	135.14	270.27	195.2							Fee Schedule		222.22							Fee Schedule																													270.27							Fee Schedule																																															
SYNTH. DRILL BIT 2.4 #310.530	270	RC						Both			491.4	221.13	221.13	442.26	319.41							Fee Schedule		363.64							Fee Schedule																													442.26							Fee Schedule																																															
SYNTH. DRILL BIT 2.7 #310.26	272	RC						Both			241.5	108.68	108.68	217.35	156.98							Fee Schedule		178.71							Fee Schedule																													217.35							Fee Schedule																																															
SYNTH. DRILL BIT 310.221	272	RC						Both			1395.45	627.95	627.95	1255.91	907.04							Fee Schedule		1032.63							Fee Schedule																													1255.91							Fee Schedule																																															
SYNTH. DRIVING CAP 03.010.475	272	RC	C1713	CPT				Both			1380.75	621.34	306.41	1242.68	306.41							Fee Schedule		1021.76							Fee Schedule																													1242.68							Fee Schedule																																															
SYNTH. ELASTIC NAIL 475.930	278	RC	C1713	CPT				Both			901.95	405.88	405.88	811.76		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	667.44							Fee Schedule																													811.76							Fee Schedule																																															
SYNTH. END CAP #458.120	278	RC	C1713	CPT				Both			285.6	128.52	128.52	257.04		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	211.34							Fee Schedule																													257.04							Fee Schedule																																															
SYNTH. EXTRACTION BOLT 357.420	272	RC						Both			1219.05	548.57	548.57	1097.15	792.38							Fee Schedule		902.1							Fee Schedule																													1097.15							Fee Schedule																																															
SYNTH. EXTRACTION SCREW 309.530	278	RC	C1713	CPT				Both			360	162	162	324		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	266.4							Fee Schedule																													324							Fee Schedule																																															
SYNTH. FEM NAIL #456.354S	278	RC	C1713	CPT				Both			4536	2041.2	2041.2	4082.4		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	3356.64							Fee Schedule																													4082.4							Fee Schedule																																															
SYNTH. FEM. NAIL. # 04.013.764S	278	RC	C1713	CPT				Both			5691	2560.95	2560.95	5121.9		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	4211.34							Fee Schedule																													5121.9							Fee Schedule																																															
SYNTH. FEM. REAM ROD W/BALL 351.76S	272	RC	C1776	CPT				Both			322.35	145.06	145.06	3875.94	3875.94							Fee Schedule		238.54							Fee Schedule																													290.12							Fee Schedule																																															
SYNTH. FEMORAL NAIL 04.013.752S	278	RC	C1713	CPT				Both			6472.2	2912.49	2912.49	5824.98		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	4789.43							Fee Schedule																													5824.98							Fee Schedule																																															
SYNTH. FEMORAL NAIL 456.418S	278	RC	C1713	CPT				Both			6932.1	3119.45	3119.45	6238.89		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	5129.75							Fee Schedule																													6238.89							Fee Schedule																																															
SYNTH. FIXATION NAIL 456.479S	278	RC	C1713	CPT				Both			5591.25	2516.06	2516.06	5032.13		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	4137.53							Fee Schedule																													5032.13							Fee Schedule																																															
SYNTH. GUIDE PIN #292.65	272	RC						Both			113.4	51.03	51.03	102.06	73.71							Fee Schedule		83.92							Fee Schedule																													102.06							Fee Schedule																																															
SYNTH. GUIDE WIRE  900.723	272	RC						Both			96.6	43.47	43.47	86.94	62.79							Fee Schedule		71.48							Fee Schedule																													86.94							Fee Schedule																																															
SYNTH. GUIDE WIRE # 02.113.001	272	RC						Both			144.9	65.21	65.21	130.41	94.19							Fee Schedule		107.23							Fee Schedule																													130.41							Fee Schedule																																															
SYNTH. GUIDE WIRE # 03.010.115	272	RC	C1769	CPT				Both			368.55	165.85	154.26	331.7	154.26							Fee Schedule		272.73							Fee Schedule																													331.7							Fee Schedule																																															
SYNTH. GUIDE WIRE #292.656	272	RC						Both			149.1	67.1	67.1	134.19	96.92							Fee Schedule		110.33							Fee Schedule																													134.19							Fee Schedule																																															
SYNTH. GUIDE WIRE 291.06	272	RC	C1769	CPT				Both			317.1	142.7	142.7	285.39	154.26							Fee Schedule		234.65							Fee Schedule																													285.39							Fee Schedule																																															
SYNTH. GUIDE WIRE 357.381	272	RC	C1769	CPT				Both			1102.5	496.13	154.26	992.25	154.26							Fee Schedule		815.85							Fee Schedule																													992.25							Fee Schedule																																															
SYNTH. HANDLE/QUICK COUPLING 311.43	270	RC						Both			16374.75	7368.64	7368.64	14737.28	10643.59							Fee Schedule		12117.32							Fee Schedule																													14737.28							Fee Schedule																																															
SYNTH. HELICAL ACREW 105MM 456.306S	278	RC	C1713	CPT				Both			1404.9	632.21	632.21	1264.41		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1039.63							Fee Schedule																													1264.41							Fee Schedule																																															
SYNTH. HUMERAL NAIL #04.001.422S	278	RC	C1713	CPT				Both			5103	2296.35	2296.35	4592.7		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	3776.22							Fee Schedule																													4592.7							Fee Schedule																																															
SYNTH. HUMERAL NAIL 7MM #04.001.240S	278	RC	C1713	CPT				Both			4649.4	2092.23	2092.23	4184.46		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	3440.56							Fee Schedule																													4184.46							Fee Schedule																																															
SYNTH. HUMERUS PLATE # 241.901	278	RC	C1713	CPT				Both			6352.5	2858.63	2858.63	5717.25		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	4700.85							Fee Schedule																													5717.25							Fee Schedule																																															
SYNTH. HUMERUS PLATE # 241.903	278	RC	C1713	CPT				Both			7014	3156.3	3156.3	6312.6		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	5190.36							Fee Schedule																													6312.6							Fee Schedule																																															
SYNTH. INSERTION HANDLE 03.010.405	270	RC						Both			16374.75	7368.64	7368.64	14737.28	10643.59							Fee Schedule		12117.32							Fee Schedule																													14737.28							Fee Schedule																																															
SYNTH. K-WIRE 292.10	278	RC						Both			40.95	18.43	18.43	36.86		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	30.3							Fee Schedule																													36.86							Fee Schedule																																															
SYNTH. K-WIRE 292.71	278	RC						Both			55.65	25.04	25.04	50.09		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	41.18							Fee Schedule																													50.09							Fee Schedule																																															
SYNTH. K-WIRE 292.73	278	RC						Both			54.6	24.57	24.57	49.14		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	40.4							Fee Schedule																													49.14							Fee Schedule																																															
SYNTH. K-WIRE 292.79	278	RC						Both			39.9	17.96	17.96	35.91		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	29.53							Fee Schedule																													35.91							Fee Schedule																																															
SYNTH. LAG SCREW  280.480S	278	RC	C1713	CPT				Both			681.45	306.65	306.65	613.31		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	504.27							Fee Schedule																													613.31							Fee Schedule																																															
SYNTH. LC-DCP PLATE #224.54	278	RC	C1713	CPT				Both			295.05	132.77	132.77	265.55		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	218.34							Fee Schedule																													265.55							Fee Schedule																																															
SYNTH. LC-DCP PLATE #224.55	278	RC	C1713	CPT				Both			295.05	132.77	132.77	265.55		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	218.34							Fee Schedule																													265.55							Fee Schedule																																															
SYNTH. LC-DCP PLATE #224.56	278	RC	C1713	CPT				Both			340.2	153.09	153.09	306.18		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	251.75							Fee Schedule																													306.18							Fee Schedule																																															
SYNTH. LC-DCP PLATE #224.57	278	RC	C1713	CPT				Both			340.2	153.09	153.09	306.18		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	251.75							Fee Schedule																													306.18							Fee Schedule																																															
SYNTH. LC-DCP PLATE #224.59	278	RC	C1713	CPT				Both			340.2	153.09	153.09	306.18		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	251.75							Fee Schedule																													306.18							Fee Schedule																																															
SYNTH. LC-DCP PLATE #224.60	278	RC	C1713	CPT				Both			453.6	204.12	204.12	408.24		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	335.66							Fee Schedule																													408.24							Fee Schedule																																															
SYNTH. LC-DCP PLATE #224.61	278	RC	C1713	CPT				Both			453.6	204.12	204.12	408.24		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	335.66							Fee Schedule																													408.24							Fee Schedule																																															
SYNTH. LC-DCP PLATE #226.56	278	RC	C1713	CPT				Both			453.6	204.12	204.12	408.24		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	335.66							Fee Schedule																													408.24							Fee Schedule																																															
SYNTH. LC-DCP PLATE #226.57	278	RC	C1713	CPT				Both			453.6	204.12	204.12	408.24		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	335.66							Fee Schedule																													408.24							Fee Schedule																																															
SYNTH. LC-DCP PLATE #226.58	278	RC	C1713	CPT				Both			567	255.15	255.15	510.3		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	419.58							Fee Schedule																													510.3							Fee Schedule																																															
SYNTH. LC-DCP PLATE #226.59	278	RC	C1713	CPT				Both			567	255.15	255.15	510.3		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	419.58							Fee Schedule																													510.3							Fee Schedule																																															
SYNTH. LC-DCP PLATE #226.60	278	RC	C1713	CPT				Both			567	255.15	255.15	510.3		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	419.58							Fee Schedule																													510.3							Fee Schedule																																															
SYNTH. LC-DCP PLATE #226.61	278	RC	C1713	CPT				Both			578.55	260.35	260.35	520.7		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	428.13							Fee Schedule																													520.7							Fee Schedule																																															
SYNTH. LC-DCP PLATE #226.62	278	RC	C1713	CPT				Both			601.65	270.74	270.74	541.49		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	445.22							Fee Schedule																													541.49							Fee Schedule																																															
SYNTH. LC-DCP PLATE #226.64	278	RC	C1713	CPT				Both			601.65	270.74	270.74	541.49		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	445.22							Fee Schedule																													541.49							Fee Schedule																																															
SYNTH. LCP PLATE #239.900	278	RC	C1713	CPT				Both			3628.8	1632.96	1632.96	3265.92		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	2685.31							Fee Schedule																													3265.92							Fee Schedule																																															
SYNTH. LCP PLATE #239.901	278	RC	C1713	CPT				Both			3628.8	1632.96	1632.96	3265.92		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	2685.31							Fee Schedule																													3265.92							Fee Schedule																																															
SYNTH. LCP PLATE 236.505	278	RC	C1713	CPT				Both			3090.15	1390.57	1390.57	2781.14		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	2286.71							Fee Schedule																													2781.14							Fee Schedule																																															
SYNTH. LCP PLATE 247.374	278	RC	C1713	CPT				Both			1414.35	636.46	636.46	1272.92		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1046.62							Fee Schedule																													1272.92							Fee Schedule																																															
SYNTH. LCP TIBIA PLATE # 238.702	278	RC	C1713	CPT				Both			4606.35	2072.86	2072.86	4145.72		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	3408.7							Fee Schedule																													4145.72							Fee Schedule																																															
SYNTH. LCP TIBIA PLATE RT #02.112.518	278	RC	C1713	CPT				Both			6313.65	2841.14	2841.14	5682.29		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	4672.1							Fee Schedule																													5682.29							Fee Schedule																																															
SYNTH. LOCKING SCREW 02.127.140	278	RC	C1713	CPT				Both			590.1	265.55	265.55	531.09		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	436.67							Fee Schedule																													531.09							Fee Schedule																																															
SYNTH. LOCKING SCREW 02.127.150	278	RC	C1713	CPT				Both			768	345.6	345.6	691.2		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	568.32							Fee Schedule																													691.2							Fee Schedule																																															
SYNTH. LOCKING SCREW 02.127.154	278	RC	C1713	CPT				Both			677.25	304.76	304.76	609.53		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	501.17							Fee Schedule																													609.53							Fee Schedule																																															
SYNTH. LOCKING SCREW 02.127.160	278	RC	C1713	CPT				Both			768	345.6	345.6	691.2		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	568.32							Fee Schedule																													691.2							Fee Schedule																																															
SYNTH. LOCKING SCREW 02.127.165	278	RC	C1713	CPT				Both			768	345.6	345.6	691.2		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	568.32							Fee Schedule																													691.2							Fee Schedule																																															
SYNTH. LOCKING SCREW 02.127.170	278	RC	C1713	CPT				Both			768	345.6	345.6	691.2		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	568.32							Fee Schedule																													691.2							Fee Schedule																																															
SYNTH. LOCKING SCREW 02.127.175	278	RC	C1713	CPT				Both			768	345.6	345.6	691.2		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	568.32							Fee Schedule																													691.2							Fee Schedule																																															
SYNTH. LOCKING SCREW 02.127.180	278	RC	C1713	CPT				Both			768	345.6	345.6	691.2		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	568.32							Fee Schedule																													691.2							Fee Schedule																																															
SYNTH. LOCKING SCREW 02.127.185	278	RC	C1713	CPT				Both			768	345.6	345.6	691.2		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	568.32							Fee Schedule																													691.2							Fee Schedule																																															
SYNTH. LOCKING SCREW 02.214.006	278	RC	C1713	CPT				Both			465.15	209.32	209.32	418.64		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	344.21							Fee Schedule																													418.64							Fee Schedule																																															
SYNTH. LOCKING SCREW 02.214.009	278	RC	C1713	CPT				Both			465.15	209.32	209.32	418.64		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	344.21							Fee Schedule																													418.64							Fee Schedule																																															
SYNTH. LOCKING SCREW 02.214.010	278	RC	C1713	CPT				Both			465.15	209.32	209.32	418.64		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	344.21							Fee Schedule																													418.64							Fee Schedule																																															
SYNTH. LOCKING SCREW 02.214.012	278	RC	C1713	CPT				Both			465.15	209.32	209.32	418.64		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	344.21							Fee Schedule																													418.64							Fee Schedule																																															
SYNTH. LOCKING SCREW 02.214.014	278	RC	C1713	CPT				Both			465.15	209.32	209.32	418.64		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	344.21							Fee Schedule																													418.64							Fee Schedule																																															
SYNTH. LOCKING SCREW 02.214.015	278	RC	C1713	CPT				Both			465.15	209.32	209.32	418.64		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	344.21							Fee Schedule																													418.64							Fee Schedule																																															
SYNTH. LOCKING SCREW 04.005.414S	278	RC	C1713	CPT				Both			847.35	381.31	381.31	762.62		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	627.04							Fee Schedule																													762.62							Fee Schedule																																															
SYNTH. LOCKING SCREW 214.816	278	RC	C1713	CPT				Both			229.95	103.48	103.48	206.96		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	170.16							Fee Schedule																													206.96							Fee Schedule																																															
SYNTH. LOCKING SCREW 214.818	278	RC	C1713	CPT				Both			56.7	25.52	25.52	51.03		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	41.96							Fee Schedule																													51.03							Fee Schedule																																															
SYNTH. MALLEO.SCREW #215.025	278	RC	C1713	CPT				Both			79.8	35.91	35.91	71.82		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	59.05							Fee Schedule																													71.82							Fee Schedule																																															
SYNTH. MALLEO.SCREW #215.030	278	RC	C1713	CPT				Both			79.8	35.91	35.91	71.82		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	59.05							Fee Schedule																													71.82							Fee Schedule																																															
SYNTH. MALLEO.SCREW #215.035	278	RC	C1713	CPT				Both			79.8	35.91	35.91	71.82		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	59.05							Fee Schedule																													71.82							Fee Schedule																																															
SYNTH. MALLEO.SCREW #215.040	278	RC	C1713	CPT				Both			79.8	35.91	35.91	71.82		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	59.05							Fee Schedule																													71.82							Fee Schedule																																															
SYNTH. MALLEO.SCREW #215.050	278	RC	C1713	CPT				Both			79.8	35.91	35.91	71.82		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	59.05							Fee Schedule																													71.82							Fee Schedule																																															
SYNTH. NAIL 456.421S	278	RC	C1713	CPT				Both			6727.35	3027.31	3027.31	6054.62		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	4978.24							Fee Schedule																													6054.62							Fee Schedule																																															
SYNTH. PLATE # 241.351	278	RC	C1713	CPT				Both			813	365.85	365.85	731.7		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	601.62							Fee Schedule																													731.7							Fee Schedule																																															
SYNTH. PLATE # 241.371	278	RC	C1713	CPT				Both			813	365.85	365.85	731.7		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	601.62							Fee Schedule																													731.7							Fee Schedule																																															
SYNTH. PLATE #442.477	278	RC	C1713	CPT				Both			1400.7	630.32	630.32	1260.63		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1036.52							Fee Schedule																													1260.63							Fee Schedule																																															
SYNTH. PLATE #442.479	278	RC	C1713	CPT				Both			1436.4	646.38	646.38	1292.76		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1062.94							Fee Schedule																													1292.76							Fee Schedule																																															
SYNTH. PLATE #442.490	278	RC	C1713	CPT				Both			1502.55	676.15	676.15	1352.3		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1111.89							Fee Schedule																													1352.3							Fee Schedule																																															
SYNTH. PLATE 4 HOLE 02.112.510	278	RC	C1713	CPT				Both			5565	2504.25	2504.25	5008.5		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	4118.1							Fee Schedule																													5008.5							Fee Schedule																																															
SYNTH. PLATE 7 HOLE 02.112.083	278	RC	C1713	CPT				Both			3176.25	1429.31	1429.31	2858.63		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	2350.43							Fee Schedule																													2858.63							Fee Schedule																																															
SYNTH. PLATE LAT DIST LT # 02.112.138	278	RC	C1713	CPT				Both			2953	1328.85	1328.85	2657.7		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	2185.22							Fee Schedule																													2657.7							Fee Schedule																																															
SYNTH. PLATE LAT DIST LT # 02.112.139	278	RC	C1713	CPT				Both			2943	1324.35	1324.35	2648.7		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	2177.82							Fee Schedule																													2648.7							Fee Schedule																																															
SYNTH. PLATE LAT DIST LT # 02.112.142	278	RC	C1713	CPT				Both			2670.15	1201.57	1201.57	2403.14		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1975.91							Fee Schedule																													2403.14							Fee Schedule																																															
SYNTH. PLATE LAT DIST LT # 02.112.143	278	RC	C1713	CPT				Both			2819.25	1268.66	1268.66	2537.33		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	2086.25							Fee Schedule																													2537.33							Fee Schedule																																															
SYNTH. PLATE LAT DIST LT # 02.112.149	278	RC	C1713	CPT				Both			2000.25	900.11	900.11	1800.23		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1480.19							Fee Schedule																													1800.23							Fee Schedule																																															
SYNTH. PLATE LAT DIST LT # 02.112.152	278	RC	C1713	CPT				Both			2031.75	914.29	914.29	1828.58		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1503.5							Fee Schedule																													1828.58							Fee Schedule																																															
SYNTH. PLATE LAT DIST LT # 02.112.153	278	RC	C1713	CPT				Both			2031.75	914.29	914.29	1828.58		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1503.5							Fee Schedule																													1828.58							Fee Schedule																																															
SYNTH. PLATE LAT DIST RT # 02.112.136	278	RC	C1713	CPT				Both			2780	1251	1251	2502		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	2057.2							Fee Schedule																													2502							Fee Schedule																																															
SYNTH. PLATE LAT DIST RT # 02.112.137	278	RC	C1713	CPT				Both			2919	1313.55	1313.55	2627.1		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	2160.06							Fee Schedule																													2627.1							Fee Schedule																																															
SYNTH. PLATE LAT DIST RT # 02.112.140	278	RC	C1713	CPT				Both			3276	1474.2	1474.2	2948.4		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	2424.24							Fee Schedule																													2948.4							Fee Schedule																																															
SYNTH. PLATE LAT DIST RT # 02.112.141	278	RC	C1713	CPT				Both			3276	1474.2	1474.2	2948.4		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	2424.24							Fee Schedule																													2948.4							Fee Schedule																																															
SYNTH. PLATE LAT DIST RT # 02.112.144	278	RC	C1713	CPT				Both			2219.7	998.87	998.87	1997.73		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1642.58							Fee Schedule																													1997.73							Fee Schedule																																															
SYNTH. PLATE LAT DIST RT # 02.112.145	278	RC	C1713	CPT				Both			2952	1328.4	1328.4	2656.8		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	2184.48							Fee Schedule																													2656.8							Fee Schedule																																															
SYNTH. PLATE LAT DIST RT # 02.112.148	278	RC	C1713	CPT				Both			3107	1398.15	1398.15	2796.3		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	2299.18							Fee Schedule																													2796.3							Fee Schedule																																															
SYNTH. PLATE LAT. DIST. LCP #02.112.157	278	RC	C1713	CPT				Both			3218.25	1448.21	1448.21	2896.43		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	2381.51							Fee Schedule																													2896.43							Fee Schedule																																															
SYNTH. PROTECTION CAPS #392.178	278	RC	C1713	CPT				Both			34.65	15.59	15.59	31.19		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	25.64							Fee Schedule																													31.19							Fee Schedule																																															
SYNTH. PROTECTION CAPS #392.179	278	RC						Both			34.65	15.59	15.59	31.19		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	25.64							Fee Schedule																													31.19							Fee Schedule																																															
SYNTH. RETROFIT KIT 690.867	272	RC						Both			299.25	134.66	134.66	269.33	194.51							Fee Schedule		221.45							Fee Schedule																													269.33							Fee Schedule																																															
SYNTH. S.T.SCREW #212.123	278	RC	C1713	CPT				Both			410.55	184.75	184.75	369.5		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	303.81							Fee Schedule																													369.5							Fee Schedule																																															
SYNTH. SAW BLADE #519.115S (ANSPACH)	272	RC						Both			362.25	163.01	163.01	326.03	235.46							Fee Schedule		268.07							Fee Schedule																													326.03							Fee Schedule																																															
SYNTH. SAW BLADE #519.117S	272	RC						Both			224.7	101.12	101.12	202.23	146.06							Fee Schedule		166.28							Fee Schedule																													202.23							Fee Schedule																																															
SYNTH. SAW BLADE 519.104S (POWER TOOLS)	272	RC						Both			305.55	137.5	137.5	275	198.61							Fee Schedule		226.11							Fee Schedule																													275							Fee Schedule																																															
SYNTH. SCREW 458.952	278	RC	C1713	CPT				Both			703.5	316.58	316.58	633.15		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	520.59							Fee Schedule																													633.15							Fee Schedule																																															
SYNTH. SCREW 458.964	278	RC	C1713	CPT				Both			808.5	363.83	363.83	727.65		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	598.29							Fee Schedule																													727.65							Fee Schedule																																															
SYNTH. SCREW 458.968	278	RC	C1713	CPT				Both			808.5	363.83	363.83	727.65		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	598.29							Fee Schedule																													727.65							Fee Schedule																																															
SYNTH. SCREW 458.972	278	RC	C1713	CPT				Both			561.75	252.79	252.79	505.58		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	415.7							Fee Schedule																													505.58							Fee Schedule																																															
SYNTH. SCREW 458.976	278	RC	C1713	CPT				Both			561.75	252.79	252.79	505.58		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	415.7							Fee Schedule																													505.58							Fee Schedule																																															
SYNTH. SCREW 458.980	278	RC	C1713	CPT				Both			561.75	252.79	252.79	505.58		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	415.7							Fee Schedule																													505.58							Fee Schedule																																															
SYNTH. SCREW 458.985	278	RC	C1713	CPT				Both			561.75	252.79	252.79	505.58		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	415.7							Fee Schedule																													505.58							Fee Schedule																																															
SYNTH. SCREW 458.990	278	RC	C1713	CPT				Both			561.75	252.79	252.79	505.58		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	415.7							Fee Schedule																													505.58							Fee Schedule																																															
SYNTH. SCREW 5.0 X 48 458.948	278	RC	C1713	CPT				Both			808.5	363.83	363.83	727.65		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	598.29							Fee Schedule																													727.65							Fee Schedule																																															
SYNTH. SCREWDRIVER 03.010.472	270	RC						Both			3402	1530.9	1530.9	3061.8	2211.3							Fee Schedule		2517.48							Fee Schedule																													3061.8							Fee Schedule																																															
SYNTH. SHORTY NAIL # 456.317S	278	RC	C1713	CPT				Both			4230.45	1903.7	1903.7	3807.41		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	3130.53							Fee Schedule																													3807.41							Fee Schedule																																															
SYNTH. SHORTY NAIL # 456.318S	278	RC	C1713	CPT				Both			6035.4	2715.93	2715.93	5431.86		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	4466.2							Fee Schedule																													5431.86							Fee Schedule																																															
SYNTH. SMALL FRAG DRLL BIT #310.67	278	RC	C1713	CPT				Both			1795	807.75	807.75	1615.5		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1328.3							Fee Schedule																													1615.5							Fee Schedule																																															
SYNTH. SMALL FRAG PLATE #241.381	278	RC	C1713	CPT				Both			868	390.6	390.6	781.2		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	642.32							Fee Schedule																													781.2							Fee Schedule																																															
SYNTH. SPIRAL BLADE 46MM	272	RC						Both			1814.4	816.48	816.48	1632.96	1179.36							Fee Schedule		1342.66							Fee Schedule																													1632.96							Fee Schedule																																															
SYNTH. STEIN PIN W/THRD 293.790	272	RC						Both			543.9	244.76	244.76	489.51	353.54							Fee Schedule		402.49							Fee Schedule																													489.51							Fee Schedule																																															
SYNTH. STEIN PIN W/THRD 293.840	272	RC						Both			600.6	270.27	270.27	540.54	390.39							Fee Schedule		444.44							Fee Schedule																													540.54							Fee Schedule																																															
SYNTH. STEIN PIN W/THRD 293.890	272	RC						Both			543.9	244.76	244.76	489.51	353.54							Fee Schedule		402.49							Fee Schedule																													489.51							Fee Schedule																																															
SYNTH. TI 5.0 LOCK SCREW #458.934	278	RC	C1713	CPT				Both			1099.35	494.71	494.71	989.42		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	813.52							Fee Schedule																													989.42							Fee Schedule																																															
SYNTH. TI CANN. TIB. NAIL #485.040S	278	RC	C1713	CPT				Both			2569.35	1156.21	1156.21	2312.42		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1901.32							Fee Schedule																													2312.42							Fee Schedule																																															
SYNTH. TI END CAP # 04.013.000S	278	RC	C1713	CPT				Both			830.55	373.75	373.75	747.5		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	614.61							Fee Schedule																													747.5							Fee Schedule																																															
SYNTH. TI HUMERAL NAIL #462.971	278	RC	C1713	CPT				Both			4536	2041.2	2041.2	4082.4		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	3356.64							Fee Schedule																													4082.4							Fee Schedule																																															
SYNTH. TI LOK SCREW # 04.005.552S	278	RC	C1713	CPT				Both			873.6	393.12	393.12	786.24		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	646.46							Fee Schedule																													786.24							Fee Schedule																																															
SYNTH. TI LOK SCREW # 04.005.570S	278	RC	C1713	CPT				Both			756	340.2	340.2	680.4		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	559.44							Fee Schedule																													680.4							Fee Schedule																																															
SYNTH. TI SPIRAL BLADE # 04.013.046S	272	RC						Both			2324.7	1046.12	1046.12	2092.23	1511.06							Fee Schedule		1720.28							Fee Schedule																													2092.23							Fee Schedule																																															
SYNTH. TI SPIRAL BLADE #462.642	278	RC	C1713	CPT				Both			1360.8	612.36	612.36	1224.72		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1006.99							Fee Schedule																													1224.72							Fee Schedule																																															
SYNTH. TI TROCH. NAIL #456.315S	278	RC	C1713	CPT				Both			5638.5	2537.33	2537.33	5074.65		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	4172.49							Fee Schedule																													5074.65							Fee Schedule																																															
SYNTH. TIBIA PLATE 238.704	278	RC	C1713	CPT				Both			4740.75	2133.34	2133.34	4266.68		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	3508.16							Fee Schedule																													4266.68							Fee Schedule																																															
SYNTH. T-PLATE #240.13	278	RC	C1713	CPT				Both			465.15	209.32	209.32	418.64		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	344.21							Fee Schedule																													418.64							Fee Schedule																																															
SYNTH. T-PLATE #240.14	278	RC	C1713	CPT				Both			533.4	240.03	240.03	480.06		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	394.72							Fee Schedule																													480.06							Fee Schedule																																															
SYNTH. T-PLATE #240.15	278	RC	C1713	CPT				Both			567	255.15	255.15	510.3		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	419.58							Fee Schedule																													510.3							Fee Schedule																																															
SYNTH. T-PLATE #240.16	278	RC	C1713	CPT				Both			623.7	280.67	280.67	561.33		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	461.54							Fee Schedule																													561.33							Fee Schedule																																															
SYNTH. T-PLATE #240.18	278	RC	C1713	CPT				Both			793.8	357.21	357.21	714.42		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	587.41							Fee Schedule																													714.42							Fee Schedule																																															
SYNTH. T-PLATE 240.141	278	RC	C1713	CPT				Both			1911	859.95	859.95	1719.9		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1414.14							Fee Schedule																													1719.9							Fee Schedule																																															
SYNTH. T-PLATE 240.161	278	RC	C1713	CPT				Both			2194.5	987.53	987.53	1975.05		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1623.93							Fee Schedule																													1975.05							Fee Schedule																																															
SYNTH. T-PLATE 240.181	278	RC	C1713	CPT				Both			2534.7	1140.62	1140.62	2281.23		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1875.68							Fee Schedule																													2281.23							Fee Schedule																																															
SYNTH. TROCAR 357.383	272	RC						Both			719.25	323.66	323.66	647.33	467.51							Fee Schedule		532.25							Fee Schedule																													647.33							Fee Schedule																																															
SYNTH. TROCH FIXATION NAIL 456.480	278	RC	C1713	CPT				Both			4176.9	1879.61	1879.61	3759.21		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	3090.91							Fee Schedule																													3759.21							Fee Schedule																																															
SYNTH. TUB. PLATE #222.04	278	RC	C1713	CPT				Both			136.5	61.43	61.43	122.85		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	101.01							Fee Schedule																													122.85							Fee Schedule																																															
SYNTH. TUB. PLATE #222.05	278	RC	C1713	CPT				Both			141.75	63.79	63.79	127.58		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	104.9							Fee Schedule																													127.58							Fee Schedule																																															
SYNTH. TUB. PLATE #222.06	278	RC	C1713	CPT				Both			141.75	63.79	63.79	127.58		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	104.9							Fee Schedule																													127.58							Fee Schedule																																															
SYNTH. TUB. PLATE #222.07	278	RC	C1713	CPT				Both			170.1	76.55	76.55	153.09		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	125.87							Fee Schedule																													153.09							Fee Schedule																																															
SYNTH. TUB. PLATE #222.08	278	RC	C1713	CPT				Both			170.1	76.55	76.55	153.09		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	125.87							Fee Schedule																													153.09							Fee Schedule																																															
SYNTH.1.0  DRILL BIT #316.396	272	RC						Both			132.3	59.54	59.54	119.07	86							Fee Schedule		97.9							Fee Schedule																													119.07							Fee Schedule																																															
SYNTH.1.0 CORT.SCREW 10MM #400.530	278	RC	C1713	CPT				Both			170.1	76.55	76.55	153.09		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	125.87							Fee Schedule																													153.09							Fee Schedule																																															
SYNTH.1.0 CORT.SCREW 11MM #400.531	278	RC	C1713	CPT				Both			170.1	76.55	76.55	153.09		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	125.87							Fee Schedule																													153.09							Fee Schedule																																															
SYNTH.1.0 CORT.SCREW 12MM #400.532	278	RC	C1713	CPT				Both			170.1	76.55	76.55	153.09		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	125.87							Fee Schedule																													153.09							Fee Schedule																																															
SYNTH.1.0 CORT.SCREW 13MM #400.533	278	RC	C1713	CPT				Both			170.1	76.55	76.55	153.09		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	125.87							Fee Schedule																													153.09							Fee Schedule																																															
SYNTH.1.0 CORT.SCREW 14MM #400.534	278	RC	C1713	CPT				Both			170.1	76.55	76.55	153.09		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	125.87							Fee Schedule																													153.09							Fee Schedule																																															
SYNTH.1.0 CORT.SCREW 6MM #400.526	278	RC	C1713	CPT				Both			170.1	76.55	76.55	153.09		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	125.87							Fee Schedule																													153.09							Fee Schedule																																															
SYNTH.1.0 CORT.SCREW 7MM #400.527	278	RC	C1713	CPT				Both			170.1	76.55	76.55	153.09		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	125.87							Fee Schedule																													153.09							Fee Schedule																																															
SYNTH.1.0 CORT.SCREW 8MM #400.528	278	RC	C1713	CPT				Both			170.1	76.55	76.55	153.09		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	125.87							Fee Schedule																													153.09							Fee Schedule																																															
SYNTH.1.0 CORT.SCREW 9MM #400.529	278	RC	C1713	CPT				Both			170.1	76.55	76.55	153.09		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	125.87							Fee Schedule																													153.09							Fee Schedule																																															
SYNTH.1.1 DRILL BIT #310.111	272	RC						Both			335	150.75	150.75	301.5	217.75							Fee Schedule		247.9							Fee Schedule																													301.5							Fee Schedule																																															
SYNTH.1.3  DRILL BIT #316.402	272	RC						Both			132.3	59.54	59.54	119.07	86							Fee Schedule		97.9							Fee Schedule																													119.07							Fee Schedule																																															
SYNTH.1.3 12HOLE PLATE 47MM #421.312	278	RC	C1713	CPT				Both			493.5	222.08	222.08	444.15		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	365.19							Fee Schedule																													444.15							Fee Schedule																																															
SYNTH.1.3 6 HOLE PLATE 23MM #421.306	278	RC	C1713	CPT				Both			388.5	174.83	174.83	349.65		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	287.49							Fee Schedule																													349.65							Fee Schedule																																															
SYNTH.1.3 CORT.SCREW 10MM #400.690	278	RC	C1713	CPT				Both			288.75	129.94	129.94	259.88		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	213.68							Fee Schedule																													259.88							Fee Schedule																																															
SYNTH.1.3 CORT.SCREW 11MM #400.691	278	RC	C1713	CPT				Both			160.65	72.29	72.29	144.59		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	118.88							Fee Schedule																													144.59							Fee Schedule																																															
SYNTH.1.3 CORT.SCREW 12MM #400.692	278	RC	C1713	CPT				Both			160.65	72.29	72.29	144.59		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	118.88							Fee Schedule																													144.59							Fee Schedule																																															
SYNTH.1.3 CORT.SCREW 13MM #400.693	278	RC	C1713	CPT				Both			160.65	72.29	72.29	144.59		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	118.88							Fee Schedule																													144.59							Fee Schedule																																															
SYNTH.1.3 CORT.SCREW 14MM #400.694	278	RC	C1713	CPT				Both			160.65	72.29	72.29	144.59		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	118.88							Fee Schedule																													144.59							Fee Schedule																																															
SYNTH.1.3 CORT.SCREW 16MM #400.696	278	RC	C1713	CPT				Both			160.65	72.29	72.29	144.59		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	118.88							Fee Schedule																													144.59							Fee Schedule																																															
SYNTH.1.3 CORT.SCREW 18MM #400.698	278	RC	C1713	CPT				Both			160.65	72.29	72.29	144.59		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	118.88							Fee Schedule																													144.59							Fee Schedule																																															
SYNTH.1.3 CORT.SCREW 6MM  #400.686	278	RC	C1713	CPT				Both			288.75	129.94	129.94	259.88		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	213.68							Fee Schedule																													259.88							Fee Schedule																																															
SYNTH.1.3 CORT.SCREW 7MM  #400.687	278	RC	C1713	CPT				Both			160.65	72.29	72.29	144.59		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	118.88							Fee Schedule																													144.59							Fee Schedule																																															
SYNTH.1.3 CORT.SCREW 8MM  #400.688	278	RC	C1713	CPT				Both			288.75	129.94	129.94	259.88		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	213.68							Fee Schedule																													259.88							Fee Schedule																																															
SYNTH.1.3 CORT.SCREW 9MM  #400.689	278	RC	C1713	CPT				Both			160.65	72.29	72.29	144.59		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	118.88							Fee Schedule																													144.59							Fee Schedule																																															
SYNTH.1.5 CORT.SCREW 10MM #400.810.96	278	RC	C1713	CPT				Both			201	90.45	90.45	180.9		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	148.74							Fee Schedule																													180.9							Fee Schedule																																															
SYNTH.1.5 CORT.SCREW 11MM #400.811.96	278	RC	C1713	CPT				Both			182.7	82.22	82.22	164.43		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	135.2							Fee Schedule																													164.43							Fee Schedule																																															
SYNTH.1.5 CORT.SCREW 12MM #400.812.96	278	RC	C1713	CPT				Both			159.6	71.82	71.82	143.64		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	118.1							Fee Schedule																													143.64							Fee Schedule																																															
SYNTH.1.5 CORT.SCREW 13MM #400.813.96	278	RC	C1713	CPT				Both			201	90.45	90.45	180.9		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	148.74							Fee Schedule																													180.9							Fee Schedule																																															
SYNTH.1.5 CORT.SCREW 14MM #400.814.96	278	RC	C1713	CPT				Both			201	90.45	90.45	180.9		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	148.74							Fee Schedule																													180.9							Fee Schedule																																															
SYNTH.1.5 CORT.SCREW 16MM #400.816.96	278	RC	C1713	CPT				Both			152.25	68.51	68.51	137.03		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	112.67							Fee Schedule																													137.03							Fee Schedule																																															
SYNTH.1.5 CORT.SCREW 18MM #400.818.96	278	RC	C1713	CPT				Both			109.2	49.14	49.14	98.28		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	80.81							Fee Schedule																													98.28							Fee Schedule																																															
SYNTH.1.5 CORT.SCREW 20MM #400.820.96	278	RC	C1713	CPT				Both			109.2	49.14	49.14	98.28		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	80.81							Fee Schedule																													98.28							Fee Schedule																																															
SYNTH.1.5 CORT.SCREW 22MM #400.822.96	278	RC	C1713	CPT				Both			109.2	49.14	49.14	98.28		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	80.81							Fee Schedule																													98.28							Fee Schedule																																															
SYNTH.1.5 CORT.SCREW 24MM #400.824.96	278	RC	C1713	CPT				Both			109.2	49.14	49.14	98.28		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	80.81							Fee Schedule																													98.28							Fee Schedule																																															
SYNTH.1.5 CORT.SCREW 6MM  #400.806.96	278	RC	C1713	CPT				Both			173.25	77.96	77.96	155.93		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	128.21							Fee Schedule																													155.93							Fee Schedule																																															
SYNTH.1.5 CORT.SCREW 7MM  #400.807.96	278	RC	C1713	CPT				Both			153.3	68.99	68.99	137.97		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	113.44							Fee Schedule																													137.97							Fee Schedule																																															
SYNTH.1.5 CORT.SCREW 8MM  #400.808.96	278	RC	C1713	CPT				Both			201	90.45	90.45	180.9		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	148.74							Fee Schedule																													180.9							Fee Schedule																																															
SYNTH.1.5 CORT.SCREW 9MM  #400.809.96	278	RC	C1713	CPT				Both			201	90.45	90.45	180.9		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	148.74							Fee Schedule																													180.9							Fee Schedule																																															
SYNTH.1.5 DRILL BIT #310.141	272	RC						Both			343.35	154.51	154.51	309.02	223.18							Fee Schedule		254.08							Fee Schedule																													309.02							Fee Schedule																																															
SYNTH.1.5 PLATE 12HOLE #446.032	278	RC	C1713	CPT				Both			493.5	222.08	222.08	444.15		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	365.19							Fee Schedule																													444.15							Fee Schedule																																															
SYNTH.1.5 PLATE 3/8 HOLE #446.233	278	RC	C1713	CPT				Both			1972	887.4	887.4	1774.8		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1459.28							Fee Schedule																													1774.8							Fee Schedule																																															
SYNTH.1.5 PLATE 4/8 HOLE #446.234	278	RC	C1713	CPT				Both			471.45	212.15	212.15	424.31		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	348.87							Fee Schedule																													424.31							Fee Schedule																																															
SYNTH.1.5 PLATE 6 HOLE #446.031	278	RC	C1713	CPT				Both			878.85	395.48	395.48	790.97		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	650.35							Fee Schedule																													790.97							Fee Schedule																																															
SYNTH.1.8  DRILL BIT #317.861	272	RC						Both			145.95	65.68	65.68	131.36	94.87							Fee Schedule		108							Fee Schedule																													131.36							Fee Schedule																																															
SYNTH.1.8 THREADED DRILL GUIDE #323.035	270	RC						Both			368.55	165.85	165.85	331.7	239.56							Fee Schedule		272.73							Fee Schedule																													331.7							Fee Schedule																																															
SYNTH.1.8 TI BUTTRESS 18MM #401.968.96	278	RC	C1713	CPT				Both			120.75	54.34	54.34	108.68		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	89.36							Fee Schedule																													108.68							Fee Schedule																																															
SYNTH.2.0 CORT.SCREW 10MM #401.810.96	278	RC	C1713	CPT				Both			193.2	86.94	86.94	173.88		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	142.97							Fee Schedule																													173.88							Fee Schedule																																															
SYNTH.2.0 CORT.SCREW 11MM #401.811.96	278	RC	C1713	CPT				Both			151.67	68.25	68.25	136.5		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	112.24							Fee Schedule																													136.5							Fee Schedule																																															
SYNTH.2.0 CORT.SCREW 12MM #401.812.96	278	RC	C1713	CPT				Both			186	83.7	83.7	167.4		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	137.64							Fee Schedule																													167.4							Fee Schedule																																															
SYNTH.2.0 CORT.SCREW 13MM #401.813.96	278	RC	C1713	CPT				Both			135.45	60.95	60.95	121.91		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	100.23							Fee Schedule																													121.91							Fee Schedule																																															
SYNTH.2.0 CORT.SCREW 14MM #401.814.96	278	RC	C1713	CPT				Both			193.2	86.94	86.94	173.88		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	142.97							Fee Schedule																													173.88							Fee Schedule																																															
SYNTH.2.0 CORT.SCREW 16MM #401.816.96	278	RC	C1713	CPT				Both			131.25	59.06	59.06	118.13		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	97.13							Fee Schedule																													118.13							Fee Schedule																																															
SYNTH.2.0 CORT.SCREW 18MM #401.818.96	278	RC	C1713	CPT				Both			131.25	59.06	59.06	118.13		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	97.13							Fee Schedule																													118.13							Fee Schedule																																															
SYNTH.2.0 CORT.SCREW 20MM #401.820.96	278	RC	C1713	CPT				Both			131.25	59.06	59.06	118.13		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	97.13							Fee Schedule																													118.13							Fee Schedule																																															
SYNTH.2.0 CORT.SCREW 22MM #401.822.96	278	RC	C1713	CPT				Both			131.25	59.06	59.06	118.13		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	97.13							Fee Schedule																													118.13							Fee Schedule																																															
SYNTH.2.0 CORT.SCREW 24MM #401.824.96	278	RC	C1713	CPT				Both			136.5	61.43	61.43	122.85		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	101.01							Fee Schedule																													122.85							Fee Schedule																																															
SYNTH.2.0 CORT.SCREW 26MM #401.826.96	278	RC	C1713	CPT				Both			131.25	59.06	59.06	118.13		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	97.13							Fee Schedule																													118.13							Fee Schedule																																															
SYNTH.2.0 CORT.SCREW 28MM #401.828.96	278	RC	C1713	CPT				Both			121.8	54.81	54.81	109.62		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	90.13							Fee Schedule																													109.62							Fee Schedule																																															
SYNTH.2.0 CORT.SCREW 30MM #401.830.96	278	RC	C1713	CPT				Both			121.8	54.81	54.81	109.62		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	90.13							Fee Schedule																													109.62							Fee Schedule																																															
SYNTH.2.0 CORT.SCREW 32MM #401.832.96	278	RC	C1713	CPT				Both			121.8	54.81	54.81	109.62		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	90.13							Fee Schedule																													109.62							Fee Schedule																																															
SYNTH.2.0 CORT.SCREW 6MM  #401.806.96	278	RC	C1713	CPT				Both			186	83.7	83.7	167.4		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	137.64							Fee Schedule																													167.4							Fee Schedule																																															
SYNTH.2.0 CORT.SCREW 7MM  #401.807.96	278	RC	C1713	CPT				Both			199.5	89.78	89.78	179.55		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	147.63							Fee Schedule																													179.55							Fee Schedule																																															
SYNTH.2.0 CORT.SCREW 8MM  #401.808.96	278	RC	C1713	CPT				Both			121.8	54.81	54.81	109.62		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	90.13							Fee Schedule																													109.62							Fee Schedule																																															
SYNTH.2.0 CORT.SCREW 9MM  #401.809.96	278	RC	C1713	CPT				Both			121.8	54.81	54.81	109.62		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	90.13							Fee Schedule																													109.62							Fee Schedule																																															
SYNTH.2.0 DRILL BIT #310.201	270	RC						Both			343.35	154.51	154.51	309.02	223.18							Fee Schedule		254.08							Fee Schedule																													309.02							Fee Schedule																																															
SYNTH.2.0 PLATE 7 HOLE #443.61.96	278	RC	C1713	CPT				Both			592.2	266.49	266.49	532.98		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	438.23							Fee Schedule																													532.98							Fee Schedule																																															
SYNTH.2.0 PLATE 7 HOLE #443.62.96	278	RC	C1713	CPT				Both			592.2	266.49	266.49	532.98		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	438.23							Fee Schedule																													532.98							Fee Schedule																																															
SYNTH.2.0 SCREW #401.808.96	278	RC	C1713	CPT				Both			162.75	73.24	73.24	146.48		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	120.44							Fee Schedule																													146.48							Fee Schedule																																															
SYNTH.2.0 SCREW #401.809.96	278	RC	C1713	CPT				Both			193.2	86.94	86.94	173.88		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	142.97							Fee Schedule																													173.88							Fee Schedule																																															
SYNTH.2.4  DRILL BIT #317.871	272	RC						Both			145.95	65.68	65.68	131.36	94.87							Fee Schedule		108							Fee Schedule																													131.36							Fee Schedule																																															
SYNTH.2.4 CORT.SCREW 10MM #401.510.96	278	RC	C1713	CPT				Both			270.9	121.91	121.91	243.81		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	200.47							Fee Schedule																													243.81							Fee Schedule																																															
SYNTH.2.4 CORT.SCREW 11MM #401.511.96	278	RC	C1713	CPT				Both			315	141.75	141.75	283.5		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	233.1							Fee Schedule																													283.5							Fee Schedule																																															
SYNTH.2.4 CORT.SCREW 12MM #401.512.96	278	RC	C1713	CPT				Both			170.1	76.55	76.55	153.09		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	125.87							Fee Schedule																													153.09							Fee Schedule																																															
SYNTH.2.4 CORT.SCREW 13MM #401.513.96	278	RC	C1713	CPT				Both			262.5	118.13	118.13	236.25		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	194.25							Fee Schedule																													236.25							Fee Schedule																																															
SYNTH.2.4 CORT.SCREW 14MM #401.514.96	278	RC	C1713	CPT				Both			221.55	99.7	99.7	199.4		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	163.95							Fee Schedule																													199.4							Fee Schedule																																															
SYNTH.2.4 CORT.SCREW 16MM #401.516.96	278	RC	C1713	CPT				Both			170.1	76.55	76.55	153.09		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	125.87							Fee Schedule																													153.09							Fee Schedule																																															
SYNTH.2.4 CORT.SCREW 18MM #401.518.96	278	RC	C1713	CPT				Both			170.1	76.55	76.55	153.09		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	125.87							Fee Schedule																													153.09							Fee Schedule																																															
SYNTH.2.4 CORT.SCREW 20MM #401.520.96	278	RC	C1713	CPT				Both			170.1	76.55	76.55	153.09		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	125.87							Fee Schedule																													153.09							Fee Schedule																																															
SYNTH.2.4 CORT.SCREW 22MM #401.522.96	278	RC	C1713	CPT				Both			170.1	76.55	76.55	153.09		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	125.87							Fee Schedule																													153.09							Fee Schedule																																															
SYNTH.2.4 CORT.SCREW 24MM #401.524.96	278	RC	C1713	CPT				Both			170.1	76.55	76.55	153.09		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	125.87							Fee Schedule																													153.09							Fee Schedule																																															
SYNTH.2.4 CORT.SCREW 26MM #401.526.96	278	RC	C1713	CPT				Both			380.1	171.05	171.05	342.09		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	281.27							Fee Schedule																													342.09							Fee Schedule																																															
SYNTH.2.4 CORT.SCREW 28MM #401.528.96	278	RC	C1713	CPT				Both			170.1	76.55	76.55	153.09		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	125.87							Fee Schedule																													153.09							Fee Schedule																																															
SYNTH.2.4 CORT.SCREW 30MM #401.530.96	278	RC	C1713	CPT				Both			170.1	76.55	76.55	153.09		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	125.87							Fee Schedule																													153.09							Fee Schedule																																															
SYNTH.2.4 CORT.SCREW 32MM #401.532.96	278	RC	C1713	CPT				Both			170.1	76.55	76.55	153.09		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	125.87							Fee Schedule																													153.09							Fee Schedule																																															
SYNTH.2.4 CORT.SCREW 6MM  #401.506.96	278	RC	C1713	CPT				Both			221.55	99.7	99.7	199.4		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	163.95							Fee Schedule																													199.4							Fee Schedule																																															
SYNTH.2.4 CORT.SCREW 7MM  #401.507.96	278	RC	C1713	CPT				Both			221.55	99.7	99.7	199.4		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	163.95							Fee Schedule																													199.4							Fee Schedule																																															
SYNTH.2.4 CORT.SCREW 8MM  #401.508.96	278	RC	C1713	CPT				Both			221.55	99.7	99.7	199.4		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	163.95							Fee Schedule																													199.4							Fee Schedule																																															
SYNTH.2.4 CORT.SCREW 9MM  #401.509.96	278	RC	C1713	CPT				Both			221.55	99.7	99.7	199.4		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	163.95							Fee Schedule																													199.4							Fee Schedule																																															
SYNTH.2.4MM CORTEX S.T. 12MM 401.512.96	278	RC	C1713	CPT				Both			262.5	118.13	118.13	236.25		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	194.25							Fee Schedule																													236.25							Fee Schedule																																															
SYNTH.2.4MM CORTEX S.T. 16MM 401.516.96	278	RC	C1713	CPT				Both			380.1	171.05	171.05	342.09		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	281.27							Fee Schedule																													342.09							Fee Schedule																																															
SYNTH.2.4MM CORTEX S.T. 18MM 401.518.96	278	RC	C1713	CPT				Both			159.6	71.82	71.82	143.64		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	118.1							Fee Schedule																													143.64							Fee Schedule																																															
SYNTH.2.4MM CORTEX S.T. 20MM 401.520.96	278	RC	C1713	CPT				Both			159.6	71.82	71.82	143.64		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	118.1							Fee Schedule																													143.64							Fee Schedule																																															
SYNTH.2.4MM CORTEX S.T. 22MM 401.522.96	278	RC	C1713	CPT				Both			380.1	171.05	171.05	342.09		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	281.27							Fee Schedule																													342.09							Fee Schedule																																															
SYNTH.2.4MM CORTEX S.T. 24MM 401.524.96	278	RC	C1713	CPT				Both			159.6	71.82	71.82	143.64		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	118.1							Fee Schedule																													143.64							Fee Schedule																																															
SYNTH.2.4MM CORTEX S.T. 28MM 401.528.96	278	RC	C1713	CPT				Both			380.1	171.05	171.05	342.09		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	281.27							Fee Schedule																													342.09							Fee Schedule																																															
SYNTH.2.4MM STR. PLATE 6 HOLE 449.906	278	RC	C1713	CPT				Both			652.05	293.42	293.42	586.85		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	482.52							Fee Schedule																													586.85							Fee Schedule																																															
SYNTH.3 FLUTED DRILL BIT 4.0MM #356.982	272	RC	C1713	CPT				Both			473.55	213.1	213.1	426.2	306.41							Fee Schedule		350.43							Fee Schedule																													426.2							Fee Schedule																																															
SYNTH.3.2 CALIB. GUIDEWIRE #292.69	272	RC	C1713	CPT				Both			283.5	127.58	127.58	306.41	306.41							Fee Schedule		209.79							Fee Schedule																													255.15							Fee Schedule																																															
SYNTH.3.5 LCP PLATE #223.561	278	RC	C1713	CPT				Both			1390	625.5	625.5	1251		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1028.6							Fee Schedule																													1251							Fee Schedule																																															
SYNTH.3.5 LOCK SELF TAP SCREW 212.124	278	RC	C1713	CPT				Both			567	255.15	255.15	510.3		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	419.58							Fee Schedule																													510.3							Fee Schedule																																															
SYNTH.3.5 S.T.SCREW 18MM #212.105	278	RC	C1713	CPT				Both			301.35	135.61	135.61	271.22		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	223							Fee Schedule																													271.22							Fee Schedule																																															
SYNTH.3.5 S.T.SCREW 20MM #212.106	278	RC	C1713	CPT				Both			567	255.15	255.15	510.3		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	419.58							Fee Schedule																													510.3							Fee Schedule																																															
SYNTH.3.5 S.T.SCREW 22MM #212.107	278	RC	C1713	CPT				Both			567	255.15	255.15	510.3		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	419.58							Fee Schedule																													510.3							Fee Schedule																																															
SYNTH.4.0 CANCELL.22MM F.T. #206.022	278	RC	C1713	CPT				Both			36.75	16.54	16.54	33.08		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	27.2							Fee Schedule																													33.08							Fee Schedule																																															
SYNTH.4.0 LOCK SCREW #222.585	278	RC	C1713	CPT				Both			299.25	134.66	134.66	269.33		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	221.45							Fee Schedule																													269.33							Fee Schedule																																															
SYNTH.4.0 LOCK SCREW #222.586	278	RC	C1713	CPT				Both			378	170.1	170.1	340.2		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	279.72							Fee Schedule																													340.2							Fee Schedule																																															
SYNTH.4.0 LOCK SCREW #458.830	278	RC	C1713	CPT				Both			425.25	191.36	191.36	382.73		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	314.69							Fee Schedule																													382.73							Fee Schedule																																															
SYNTH.4.0 LOCK SCREW #458.844	278	RC	C1713	CPT				Both			425.25	191.36	191.36	382.73		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	314.69							Fee Schedule																													382.73							Fee Schedule																																															
SYNTH.4.0 SCREW  206.424	278	RC	C1713	CPT				Both			54.6	24.57	24.57	49.14		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	40.4							Fee Schedule																													49.14							Fee Schedule																																															
SYNTH.4.0 SCREW  206.426	278	RC	C1713	CPT				Both			54.6	24.57	24.57	49.14		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	40.4							Fee Schedule																													49.14							Fee Schedule																																															
SYNTH.4.0 SCREW  206.430	278	RC	C1713	CPT				Both			54.6	24.57	24.57	49.14		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	40.4							Fee Schedule																													49.14							Fee Schedule																																															
SYNTH.4.0 SCREW  206.436	278	RC	C1713	CPT				Both			54.6	24.57	24.57	49.14		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	40.4							Fee Schedule																													49.14							Fee Schedule																																															
SYNTH.5 HOLE ANGLE PLATE #237.053	278	RC	C1713	CPT				Both			2494.8	1122.66	1122.66	2245.32		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1846.15							Fee Schedule																													2245.32							Fee Schedule																																															
SYNTH.5.0 BOLT 38MM #458.938S	278	RC	C1713	CPT				Both			454.65	204.59	204.59	409.19		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	336.44							Fee Schedule																													409.19							Fee Schedule																																															
SYNTH.5.0 BOLT 44MM #458.944S	278	RC	C1713	CPT				Both			454.65	204.59	204.59	409.19		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	336.44							Fee Schedule																													409.19							Fee Schedule																																															
SYNTH.5.0 LOCK SCREW #222.546	278	RC	C1713	CPT				Both			528.15	237.67	237.67	475.34		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	390.83							Fee Schedule																													475.34							Fee Schedule																																															
SYNTH.5.0 LOCK SCREW #222.547	278	RC	C1713	CPT				Both			416.85	187.58	187.58	375.17		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	308.47							Fee Schedule																													375.17							Fee Schedule																																															
SYNTH.5.0 SCREW #458.932	278	RC	C1713	CPT				Both			425.25	191.36	191.36	382.73		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	314.69							Fee Schedule																													382.73							Fee Schedule																																															
SYNTH.6.0 SCREW #450.868	278	RC	C1713	CPT				Both			453.6	204.12	204.12	408.24		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	335.66							Fee Schedule																													408.24							Fee Schedule																																															
SYNTH.COMBO CLAMP LARGE #390.005	278	RC	C1713	CPT				Both			3168.9	1426.01	1426.01	2852.01		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	2344.99							Fee Schedule																													2852.01							Fee Schedule																																															
SYNTH.COND. PLATE 7 HOLE #446.63.96	278	RC	C1713	CPT				Both			592.2	266.49	266.49	532.98		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	438.23							Fee Schedule																													532.98							Fee Schedule																																															
SYNTH.COND. PLATE 7 HOLE #446.64.96	278	RC	C1713	CPT				Both			592.2	266.49	266.49	532.98		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	438.23							Fee Schedule																													532.98							Fee Schedule																																															
SYNTH.CONDYLAR  8 HOLE #449.916	278	RC	C1713	CPT				Both			620.55	279.25	279.25	558.5		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	459.21							Fee Schedule																													558.5							Fee Schedule																																															
SYNTH.CONDYLAR  8 HOLE #449.917	278	RC	C1713	CPT				Both			620.55	279.25	279.25	558.5		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	459.21							Fee Schedule																													558.5							Fee Schedule																																															
SYNTH.DELIVERY NEEDLE #DLS-7103-01S	272	RC	C1713	CPT				Both			222.6	100.17	100.17	306.41	306.41							Fee Schedule		164.72							Fee Schedule																													200.34							Fee Schedule																																															
SYNTH.DELIVERY NEEDLE #DLS-7122-01S	272	RC						Both			170.1	76.55	76.55	153.09	110.57							Fee Schedule		125.87							Fee Schedule																													153.09							Fee Schedule																																															
SYNTH.DELIVERY NEEDLE #DLS-7123-05S	272	RC						Both			680.4	306.18	306.18	612.36	442.26							Fee Schedule		503.5							Fee Schedule																													612.36							Fee Schedule																																															
SYNTH.DELIVERY SYRINGE #DLS-2000-0S	272	RC						Both			567	255.15	255.15	510.3	368.55							Fee Schedule		419.58							Fee Schedule																													510.3							Fee Schedule																																															
SYNTH.DHS/DCS COMP.SCREW 36MM 280.990	278	RC	C1713	CPT				Both			203.7	91.67	91.67	183.33		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	150.74							Fee Schedule																													183.33							Fee Schedule																																															
SYNTH.DIST.MEDIAL TIB.PLATE 223.506	278	RC	C1713	CPT				Both			1024.8	461.16	461.16	922.32		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	758.35							Fee Schedule																													922.32							Fee Schedule																																															
SYNTH.DISTAL FEMORAL NAIL #450.848S	278	RC	C1713	CPT				Both			4082.4	1837.08	1837.08	3674.16		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	3020.98							Fee Schedule																													3674.16							Fee Schedule																																															
SYNTH.DISTAL RADIUS PLATE 242.472	278	RC	C1713	CPT				Both			1647.45	741.35	741.35	1482.71		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1219.11							Fee Schedule																													1482.71							Fee Schedule																																															
SYNTH.DRILL BIT #315.40	272	RC						Both			677.25	304.76	304.76	609.53	440.21							Fee Schedule		501.17							Fee Schedule																													609.53							Fee Schedule																																															
SYNTH.EDIST.FEM.NAIL#450.805S	278	RC	C1713	CPT				Both			4082.4	1837.08	1837.08	3674.16		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	3020.98							Fee Schedule																													3674.16							Fee Schedule																																															
SYNTH.GUIDE LCP 03.123.010	270	RC						Both			5224.8	2351.16	2351.16	4702.32	3396.12							Fee Schedule		3866.35							Fee Schedule																													4702.32							Fee Schedule																																															
SYNTH.GUIDE LCP 03.123.011	270	RC						Both			5224.8	2351.16	2351.16	4702.32	3396.12							Fee Schedule		3866.35							Fee Schedule																													4702.32							Fee Schedule																																															
SYNTH.GUIDE WIRE 357.399	272	RC	C1769	CPT				Both			504	226.8	154.26	453.6	154.26							Fee Schedule		372.96							Fee Schedule																													453.6							Fee Schedule																																															
SYNTH.H PLATE LEFT  #421.321	278	RC	C1713	CPT				Both			471.45	212.15	212.15	424.31		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	348.87							Fee Schedule																													424.31							Fee Schedule																																															
SYNTH.H PLATE LEFT  #446.483	278	RC	C1713	CPT				Both			471.45	212.15	212.15	424.31		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	348.87							Fee Schedule																													424.31							Fee Schedule																																															
SYNTH.H PLATE RIGHT #421.320	278	RC	C1713	CPT				Both			471.45	212.15	212.15	424.31		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	348.87							Fee Schedule																													424.31							Fee Schedule																																															
SYNTH.H PLATE RIGHT #446.482	278	RC	C1713	CPT				Both			471.45	212.15	212.15	424.31		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	348.87							Fee Schedule																													424.31							Fee Schedule																																															
SYNTH.HELICAL SCREW #456.305	278	RC	C1713	CPT				Both			2491.65	1121.24	1121.24	2242.49		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1843.82							Fee Schedule																													2242.49							Fee Schedule																																															
SYNTH.HELICAL SCREW BLADE #456.309	278	RC	C1713	CPT				Both			2491.65	1121.24	1121.24	2242.49		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1843.82							Fee Schedule																													2242.49							Fee Schedule																																															
SYNTH.HELICAL SCREW BLADE #462.640	278	RC	C1713	CPT				Both			1360.8	612.36	612.36	1224.72		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1006.99							Fee Schedule																													1224.72							Fee Schedule																																															
SYNTH.HIP PLATE 135 DEG.4 HOLE 281.140	278	RC	C1713	CPT				Both			1044.75	470.14	470.14	940.28		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	773.12							Fee Schedule																													940.28							Fee Schedule																																															
SYNTH.HIP PLATE 135 DEG.4 HOLE 281.540	278	RC	C1713	CPT				Both			1044.75	470.14	470.14	940.28		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	773.12							Fee Schedule																													940.28							Fee Schedule																																															
SYNTH.HIP PLATE 135 DEG.5 HOLE 281.150	278	RC	C1713	CPT				Both			1044.75	470.14	470.14	940.28		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	773.12							Fee Schedule																													940.28							Fee Schedule																																															
SYNTH.HIP PLATE 135 DEG.6 HOLE 281.160	278	RC	C1713	CPT				Both			1134	510.3	510.3	1020.6		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	839.16							Fee Schedule																													1020.6							Fee Schedule																																															
SYNTH.HIP PLATE 140 DEG.4 HOLE 281.240	278	RC	C1713	CPT				Both			1044.75	470.14	470.14	940.28		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	773.12							Fee Schedule																													940.28							Fee Schedule																																															
SYNTH.HIP PLATE 140 DEG.5 HOLE 281.250	278	RC	C1713	CPT				Both			1044.75	470.14	470.14	940.28		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	773.12							Fee Schedule																													940.28							Fee Schedule																																															
SYNTH.HIP PLATE 140 DEG.6 HOLE 281.260	278	RC	C1713	CPT				Both			1044.75	470.14	470.14	940.28		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	773.12							Fee Schedule																													940.28							Fee Schedule																																															
SYNTH.HIP PLATE 145 DEG.4 HOLE 281.340	278	RC	C1713	CPT				Both			1134	510.3	510.3	1020.6		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	839.16							Fee Schedule																													1020.6							Fee Schedule																																															
SYNTH.HIP PLATE 145 DEG.5 HOLE 281.350	278	RC	C1713	CPT				Both			1044.75	470.14	470.14	940.28		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	773.12							Fee Schedule																													940.28							Fee Schedule																																															
SYNTH.HIP PLATE 145 DEG.6 HOLE 281.360	278	RC	C1713	CPT				Both			1044.75	470.14	470.14	940.28		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	773.12							Fee Schedule																													940.28							Fee Schedule																																															
SYNTH.HIP PLATE 150 DEG.4 HOLE 281.440	278	RC	C1713	CPT				Both			1134	510.3	510.3	1020.6		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	839.16							Fee Schedule																													1020.6							Fee Schedule																																															
SYNTH.HIP PLATE 150 DEG.4 HOLE 281.840	278	RC	C1713	CPT				Both			1044.75	470.14	470.14	940.28		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	773.12							Fee Schedule																													940.28							Fee Schedule																																															
SYNTH.HIP PLATE 150 DEG.5 HOLE 281.450	278	RC	C1713	CPT				Both			1044.75	470.14	470.14	940.28		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	773.12							Fee Schedule																													940.28							Fee Schedule																																															
SYNTH.HIP PLATE 150 DEG.6 HOLE 281.460	278	RC	C1713	CPT				Both			1044.75	470.14	470.14	940.28		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	773.12							Fee Schedule																													940.28							Fee Schedule																																															
SYNTH.HUM.NAIL PROX. #04.001.410S	278	RC	C1713	CPT				Both			5670	2551.5	2551.5	5103		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	4195.8							Fee Schedule																													5103							Fee Schedule																																															
SYNTH.K-WIRE DOUBLE 1.0 #292.50	278	RC						Both			34.65	15.59	15.59	31.19		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	25.64							Fee Schedule																													31.19							Fee Schedule																																															
SYNTH.K-WIRE DOUBLE 1.6 #292.56	278	RC						Both			48.3	21.74	21.74	43.47		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	35.74							Fee Schedule																													43.47							Fee Schedule																																															
SYNTH.K-WIRE DOUBLE 2.0 #292.52	278	RC						Both			34.65	15.59	15.59	31.19		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	25.64							Fee Schedule																													31.19							Fee Schedule																																															
SYNTH.K-WIRE DOUBLE 2.0 #292.58	278	RC						Both			34.65	15.59	15.59	31.19		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	25.64							Fee Schedule																													31.19							Fee Schedule																																															
SYNTH.LC-DCP PLATE 4 HOLE #449.924	278	RC	C1713	CPT				Both			788.55	354.85	354.85	709.7		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	583.53							Fee Schedule																													709.7							Fee Schedule																																															
SYNTH.LC-DCP PLATE 4 HOLE #449.931	278	RC	C1713	CPT				Both			924	415.8	415.8	831.6		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	683.76							Fee Schedule																													831.6							Fee Schedule																																															
SYNTH.LC-DCP PLATE 6 HOLE #449.926	278	RC	C1713	CPT				Both			745.5	335.48	335.48	670.95		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	551.67							Fee Schedule																													670.95							Fee Schedule																																															
SYNTH.LC-DCP PLATE 6 HOLE #449.936	278	RC	C1713	CPT				Both			1221.89	549.85	549.85	1099.7		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	904.2							Fee Schedule																													1099.7							Fee Schedule																																															
SYNTH.LC-DCP PLATE 8 HOLE #449.928	278	RC	C1713	CPT				Both			1117.2	502.74	502.74	1005.48		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	826.73							Fee Schedule																													1005.48							Fee Schedule																																															
SYNTH.LC-DCP PLATE 8 HOLE #449.938	278	RC	C1713	CPT				Both			1525.65	686.54	686.54	1373.09		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1128.98							Fee Schedule																													1373.09							Fee Schedule																																															
SYNTH.LCP PROX. TIB. PLATE #240.038	278	RC	C1713	CPT				Both			5608.05	2523.62	2523.62	5047.25		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	4149.96							Fee Schedule																													5047.25							Fee Schedule																																															
SYNTH.LG. FRAG SCREW #214.030	278	RC	C1713	CPT				Both			46.2	20.79	20.79	41.58		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	34.19							Fee Schedule																													41.58							Fee Schedule																																															
SYNTH.LG. FRAG SCREW #214.032	278	RC	C1713	CPT				Both			46.2	20.79	20.79	41.58		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	34.19							Fee Schedule																													41.58							Fee Schedule																																															
SYNTH.LG. FRAG SCREW #214.034	278	RC	C1713	CPT				Both			46.2	20.79	20.79	41.58		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	34.19							Fee Schedule																													41.58							Fee Schedule																																															
SYNTH.LG. FRAG SCREW #214.036	278	RC	C1713	CPT				Both			46.2	20.79	20.79	41.58		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	34.19							Fee Schedule																													41.58							Fee Schedule																																															
SYNTH.LG. FRAG SCREW #214.038	278	RC	C1713	CPT				Both			46.2	20.79	20.79	41.58		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	34.19							Fee Schedule																													41.58							Fee Schedule																																															
SYNTH.LG. FRAG SCREW #214.040	278	RC	C1713	CPT				Both			46.2	20.79	20.79	41.58		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	34.19							Fee Schedule																													41.58							Fee Schedule																																															
SYNTH.LG. FRAG SCREW #214.042	278	RC	C1713	CPT				Both			46.2	20.79	20.79	41.58		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	34.19							Fee Schedule																													41.58							Fee Schedule																																															
SYNTH.LG. FRAG SCREW #214.050	278	RC	C1713	CPT				Both			46.2	20.79	20.79	41.58		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	34.19							Fee Schedule																													41.58							Fee Schedule																																															
SYNTH.LG. FRAG SCREW #214.066	278	RC	C1713	CPT				Both			46.2	20.79	20.79	41.58		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	34.19							Fee Schedule																													41.58							Fee Schedule																																															
SYNTH.LG. FRAG SCREW #214.068	278	RC	C1713	CPT				Both			46.2	20.79	20.79	41.58		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	34.19							Fee Schedule																													41.58							Fee Schedule																																															
SYNTH.LG. FRAG SCREW #216.050	278	RC	C1713	CPT				Both			124.95	56.23	56.23	112.46		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	92.46							Fee Schedule																													112.46							Fee Schedule																																															
SYNTH.LG. FRAG SCREW #216.065	278	RC	C1713	CPT				Both			91.35	41.11	41.11	82.22		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	67.6							Fee Schedule																													82.22							Fee Schedule																																															
SYNTH.LG. FRAG SCREW #216.075	278	RC	C1713	CPT				Both			91.35	41.11	41.11	82.22		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	67.6							Fee Schedule																													82.22							Fee Schedule																																															
SYNTH.LG. FRAG SCREW #217.075	278	RC	C1713	CPT				Both			91.35	41.11	41.11	82.22		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	67.6							Fee Schedule																													82.22							Fee Schedule																																															
SYNTH.LG. FRAG SCREW #217.085	278	RC	C1713	CPT				Both			91.35	41.11	41.11	82.22		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	67.6							Fee Schedule																													82.22							Fee Schedule																																															
SYNTH.LG. FRAG SCREW #217.095	278	RC	C1713	CPT				Both			91.35	41.11	41.11	82.22		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	67.6							Fee Schedule																													82.22							Fee Schedule																																															
SYNTH.LG. PIN  6 POSITION # 390.010	278	RC	C1713	CPT				Both			1814.4	816.48	816.48	1632.96		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1342.66							Fee Schedule																													1632.96							Fee Schedule																																															
SYNTH.LG. PIN 4 POSITION # 390.009	278	RC	C1713	CPT				Both			1617	727.65	727.65	1455.3		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1196.58							Fee Schedule																													1455.3							Fee Schedule																																															
SYNTH.LG.ADJ.CLAMP # 390.008	270	RC						Both			2625	1181.25	1181.25	2362.5	1706.25							Fee Schedule		1942.5							Fee Schedule																													2362.5							Fee Schedule																																															
SYNTH.LOCK SCREW 30MM #04.005.420S	278	RC	C1713	CPT				Both			873.6	393.12	393.12	786.24		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	646.46							Fee Schedule																													786.24							Fee Schedule																																															
SYNTH.LOCKING SCREW 12MM 202.208	278	RC	C1713	CPT				Both			533.4	240.03	240.03	480.06		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	394.72							Fee Schedule																													480.06							Fee Schedule																																															
SYNTH.LOCKING SCREW 12MM 202.210	278	RC	C1713	CPT				Both			524	235.8	235.8	471.6		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	387.76							Fee Schedule																													471.6							Fee Schedule																																															
SYNTH.LOCKING SCREW 12MM 202.212	278	RC	C1713	CPT				Both			599	269.55	269.55	539.1		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	443.26							Fee Schedule																													539.1							Fee Schedule																																															
SYNTH.LOCKING SCREW 12MM 202.220	278	RC	C1713	CPT				Both			499	224.55	224.55	449.1		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	369.26							Fee Schedule																													449.1							Fee Schedule																																															
SYNTH.LOCKING SCREW 12MM 202.222	278	RC	C1713	CPT				Both			532.98	239.84	239.84	479.68		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	394.41							Fee Schedule																													479.68							Fee Schedule																																															
SYNTH.LOCKING SCREW 12MM 202.224	278	RC	C1713	CPT				Both			603	271.35	271.35	542.7		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	446.22							Fee Schedule																													542.7							Fee Schedule																																															
SYNTH.LOCKING SCREW 12MM 202.226	278	RC	C1713	CPT				Both			402.15	180.97	180.97	361.94		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	297.59							Fee Schedule																													361.94							Fee Schedule																																															
SYNTH.LOCKING SCREW 12MM 202.228	278	RC	C1713	CPT				Both			402.15	180.97	180.97	361.94		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	297.59							Fee Schedule																													361.94							Fee Schedule																																															
SYNTH.LOCKING SCREW 12MM 202.230	278	RC	C1713	CPT				Both			532.98	239.84	239.84	479.68		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	394.41							Fee Schedule																													479.68							Fee Schedule																																															
SYNTH.LOCKING SCREW 14MM 202.214	278	RC	C1713	CPT				Both			524	235.8	235.8	471.6		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	387.76							Fee Schedule																													471.6							Fee Schedule																																															
SYNTH.LOCKING SCREW 16MM 202.216	278	RC	C1713	CPT				Both			524	235.8	235.8	471.6		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	387.76							Fee Schedule																													471.6							Fee Schedule																																															
SYNTH.LOCKING SCREW 18MM 202.218	278	RC	C1713	CPT				Both			524	235.8	235.8	471.6		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	387.76							Fee Schedule																													471.6							Fee Schedule																																															
SYNTH.LOCKING SCREW 26MM #212.109	278	RC	C1713	CPT				Both			527.1	237.2	237.2	474.39		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	390.05							Fee Schedule																													474.39							Fee Schedule																																															
SYNTH.LOCKING SCREW 30MM #212.111	278	RC	C1713	CPT				Both			721.35	324.61	324.61	649.22		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	533.8							Fee Schedule																													649.22							Fee Schedule																																															
SYNTH.LOCKING SCREW 34MM #212.113	278	RC	C1713	CPT				Both			642	288.9	288.9	577.8		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	475.08							Fee Schedule																													577.8							Fee Schedule																																															
SYNTH.LOCKING SCREW 36MM #212.115	278	RC	C1713	CPT				Both			642	288.9	288.9	577.8		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	475.08							Fee Schedule																													577.8							Fee Schedule																																															
SYNTH.LOCKING SCREW 38MM #212.116	278	RC	C1713	CPT				Both			527.1	237.2	237.2	474.39		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	390.05							Fee Schedule																													474.39							Fee Schedule																																															
SYNTH.PLATE 3/8 HOLE #421.333	278	RC	C1713	CPT				Both			451.5	203.18	203.18	406.35		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	334.11							Fee Schedule																													406.35							Fee Schedule																																															
SYNTH.PLATE 3/8 HOLE #421.335	278	RC	C1713	CPT				Both			451.5	203.18	203.18	406.35		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	334.11							Fee Schedule																													406.35							Fee Schedule																																															
SYNTH.PLATE 4/8 HOLE #421.334	278	RC	C1713	CPT				Both			471.45	212.15	212.15	424.31		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	348.87							Fee Schedule																													424.31							Fee Schedule																																															
SYNTH.PROTECTIVE CAPS # 394.97	278	RC						Both			6.3	2.84	2.84	5.67		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	4.66							Fee Schedule																													5.67							Fee Schedule																																															
SYNTH.PROTECTIVE CAPS # 394.991	278	RC						Both			18.9	8.51	8.51	17.01		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	13.99							Fee Schedule																													17.01							Fee Schedule																																															
SYNTH.PROTECTIVE CAPS # 394.992	278	RC						Both			18.9	8.51	8.51	17.01		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	13.99							Fee Schedule																													17.01							Fee Schedule																																															
SYNTH.PROTECTIVE CAPS # 394.993	278	RC						Both			18.9	8.51	8.51	17.01		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	13.99							Fee Schedule																													17.01							Fee Schedule																																															
SYNTH.PROTECTIVE CAPS # 394.994	278	RC						Both			18.9	8.51	8.51	17.01		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	13.99							Fee Schedule																													17.01							Fee Schedule																																															
SYNTH.REAM.ROD BALL TIP 3.0  351.768	272	RC						Both			303.45	136.55	136.55	273.11	197.24							Fee Schedule		224.55							Fee Schedule																													273.11							Fee Schedule																																															
SYNTH.SCHZ.SCREW 80MM # 294.786	278	RC	C1713	CPT				Both			850.5	382.73	382.73	765.45		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	629.37							Fee Schedule																													765.45							Fee Schedule																																															
SYNTH.SCREW 4.0X26 #458.826S	278	RC	C1713	CPT				Both			510.3	229.64	229.64	459.27		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	377.62							Fee Schedule																													459.27							Fee Schedule																																															
SYNTH.SCREW 5.0 #458.930S	278	RC	C1713	CPT				Both			567	255.15	255.15	510.3		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	419.58							Fee Schedule																													510.3							Fee Schedule																																															
SYNTH.SCREW 6.0 #450.867	278	RC	C1713	CPT				Both			481.95	216.88	216.88	433.76		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	356.64							Fee Schedule																													433.76							Fee Schedule																																															
SYNTH.SCREW 6.0 SCREW #450.865	278	RC	C1713	CPT				Both			481.95	216.88	216.88	433.76		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	356.64							Fee Schedule																													433.76							Fee Schedule																																															
SYNTH.SHORT PLATE R #241.622	278	RC	C1713	CPT				Both			3334.8	1500.66	1500.66	3001.32		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	2467.75							Fee Schedule																													3001.32							Fee Schedule																																															
SYNTH.STAINLESS STEEL P. #391.82	272	RC	C1713	CPT				Both			1100.4	495.18	306.41	990.36	306.41							Fee Schedule		814.3							Fee Schedule																													990.36							Fee Schedule																																															
SYNTH.STEIN PIN W/THRD. 293.940	278	RC	C1713	CPT				Both			643.65	289.64	289.64	579.29		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	476.3							Fee Schedule																													579.29							Fee Schedule																																															
SYNTH.STRA PLATE 12 HOLE#449.912	278	RC	C1713	CPT				Both			557.55	250.9	250.9	501.8		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	412.59							Fee Schedule																													501.8							Fee Schedule																																															
SYNTH.STRA PLATE 6 HOLE #449.906	278	RC	C1713	CPT				Both			652.05	293.42	293.42	586.85		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	482.52							Fee Schedule																													586.85							Fee Schedule																																															
SYNTH.STRA. PLATE 12 HOLE#447.032	278	RC	C1713	CPT				Both			516.6	232.47	232.47	464.94		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	382.28							Fee Schedule																													464.94							Fee Schedule																																															
SYNTH.STRA. PLATE 6 HOLE #447.031	278	RC	C1713	CPT				Both			2175	978.75	978.75	1957.5		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1609.5							Fee Schedule																													1957.5							Fee Schedule																																															
SYNTH.TEN IM.M. NAIL #456.482S	278	RC	C1713	CPT				Both			4536	2041.2	2041.2	4082.4		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	3356.64							Fee Schedule																													4082.4							Fee Schedule																																															
SYNTH.THREADED GUIDE WIRE 2.5MM 900.723	278	RC						Both			157.5	70.88	70.88	141.75		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	116.55							Fee Schedule																													141.75							Fee Schedule																																															
SYNTH.TI FIX NAIL 130DEG.#456.322S	278	RC	C1713	CPT				Both			6035.4	2715.93	2715.93	5431.86		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	4466.2							Fee Schedule																													5431.86							Fee Schedule																																															
SYNTH.TI HELICAL BLADE 95MM #456.304S	272	RC						Both			1312.5	590.63	590.63	1181.25	853.13							Fee Schedule		971.25							Fee Schedule																													1181.25							Fee Schedule																																															
SYNTH.TIBIAL IM NAIL #456.472S	278	RC	C1713	CPT				Both			3902.85	1756.28	1756.28	3512.57		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	2888.11							Fee Schedule																													3512.57							Fee Schedule																																															
SYNTH.T-PLATE 2/8 HOLE #449.913	278	RC	C1713	CPT				Both			531.3	239.09	239.09	478.17		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	393.16							Fee Schedule																													478.17							Fee Schedule																																															
SYNTH.T-PLATE 2/8HOLE #447.232	278	RC	C1713	CPT				Both			895.65	403.04	403.04	806.09		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	662.78							Fee Schedule																													806.09							Fee Schedule																																															
SYNTH.T-PLATE 3/8 HOLE #447.233	278	RC	C1713	CPT				Both			515.55	232	232	464		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	381.51							Fee Schedule																													464							Fee Schedule																																															
SYNTH.T-PLATE 3/8 HOLE #449.914	278	RC	C1713	CPT				Both			565.95	254.68	254.68	509.36		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	418.8							Fee Schedule																													509.36							Fee Schedule																																															
SYNTH.TROCH FEM NAIL #456.477S	278	RC	C1713	CPT				Both			5406.45	2432.9	2432.9	4865.81		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	4000.77							Fee Schedule																													4865.81							Fee Schedule																																															
SYNTH.TROCH FEM NAIL #456.478S	278	RC	C1713	CPT				Both			4309.2	1939.14	1939.14	3878.28		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	3188.81							Fee Schedule																													3878.28							Fee Schedule																																															
SYNTH.WRIST FUSION PLATE #242.510	278	RC	C1713	CPT				Both			2155.65	970.04	970.04	1940.09		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1595.18							Fee Schedule																													1940.09							Fee Schedule																																															
SYNTH.Y PLATE 3/8 HOLE #446.612	278	RC	C1713	CPT				Both			451.5	203.18	203.18	406.35		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	334.11							Fee Schedule																													406.35							Fee Schedule																																															
SYNTH.Y-PLATE 3/8 HOLE #447.612	278	RC	C1713	CPT				Both			515.55	232	232	464		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	381.51							Fee Schedule																													464							Fee Schedule																																															
SYNTH.Y-PLATE 3/8 HOLE #449.915	278	RC	C1713	CPT				Both			547.05	246.17	246.17	492.35		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	404.82							Fee Schedule																													492.35							Fee Schedule																																															
SYNTHENS HUMERAL NAIL 04.001.238S	278	RC	C1713	CPT				Both			6117.3	2752.79	2752.79	5505.57		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	4526.8							Fee Schedule																													5505.57							Fee Schedule																																															
SYNTHES 10 HOLE PLATE 223.601	278	RC	C1713	CPT				Both			1860	837	837	1674		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1376.4							Fee Schedule																													1674							Fee Schedule																																															
SYNTHES 11MM  CANN FIX. NAIL #456.419S	278	RC	C1713	CPT				Both			7419.3	3338.69	3338.69	6677.37		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	5490.28							Fee Schedule																													6677.37							Fee Schedule																																															
SYNTHES 11MM FIXATION NAIL 456.422S	278	RC	C1713	CPT				Both			7941.15	3573.52	3573.52	7147.04		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	5876.45							Fee Schedule																													7147.04							Fee Schedule																																															
SYNTHES 11MM FIXATION NAIL 456.423S	278	RC	C1713	CPT				Both			7941.15	3573.52	3573.52	7147.04		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	5876.45							Fee Schedule																													7147.04							Fee Schedule																																															
SYNTHES 3 HOLE PLATE 241.031	278	RC	C1713	CPT				Both			953.4	429.03	429.03	858.06		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	705.52							Fee Schedule																													858.06							Fee Schedule																																															
SYNTHES 3.2 MM DRILL BIT 03.101.103S	270	RC						Both			528.15	237.67	237.67	475.34	343.3							Fee Schedule		390.83							Fee Schedule																													475.34							Fee Schedule																																															
SYNTHES 3.5 14MM LOCKED SCREW 212.103	278	RC	C1713	CPT				Both			567	255.15	255.15	510.3		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	419.58							Fee Schedule																													510.3							Fee Schedule																																															
SYNTHES 3.5 CORTEX SCREW 12MM #204.012	278	RC	C1713	CPT				Both			110.25	49.61	49.61	99.23		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	81.59							Fee Schedule																													99.23							Fee Schedule																																															
SYNTHES 3.5 CORTEX SCREW 18MM #204.018	278	RC	C1713	CPT				Both			110.25	49.61	49.61	99.23		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	81.59							Fee Schedule																													99.23							Fee Schedule																																															
SYNTHES 3.5 LOCK SCREW 212.101	278	RC	C1713	CPT				Both			567	255.15	255.15	510.3		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	419.58							Fee Schedule																													510.3							Fee Schedule																																															
SYNTHES 3.5 LOCKING SCREW 24MM 212.108	278	RC	C1713	CPT				Both			567	255.15	255.15	510.3		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	419.58							Fee Schedule																													510.3							Fee Schedule																																															
SYNTHES 3.5MM LOCKING SCREW #02.127.144	278	RC	C1713	CPT				Both			768	345.6	345.6	691.2		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	568.32							Fee Schedule																													691.2							Fee Schedule																																															
SYNTHES 4.0 CANNULATED SHORT 407.646	278	RC	C1713	CPT				Both			927.05	417.17	417.17	834.35		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	686.02							Fee Schedule																													834.35							Fee Schedule																																															
SYNTHES 4.5 CORTEX SCREW 32 MM 214.832	278	RC	C1713	CPT				Both			229.95	103.48	103.48	206.96		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	170.16							Fee Schedule																													206.96							Fee Schedule																																															
SYNTHES 4.5MM LCP FEMUR PLATE RT 242.806	278	RC	C1713	CPT				Both			9468.9	4261.01	4261.01	8522.01		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	7006.99							Fee Schedule																													8522.01							Fee Schedule																																															
SYNTHES 5.0 LOCK SCREW # 04.005.520S	278	RC	C1713	CPT				Both			733.95	330.28	330.28	660.56		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	543.12							Fee Schedule																													660.56							Fee Schedule																																															
SYNTHES 5.0 LOCK SCREW # 04.005.524S	278	RC	C1713	CPT				Both			847.35	381.31	381.31	762.62		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	627.04							Fee Schedule																													762.62							Fee Schedule																																															
SYNTHES 5.0 SCREW  458.954	278	RC	C1713	CPT				Both			754.16	339.37	339.37	678.74		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	558.08							Fee Schedule																													678.74							Fee Schedule																																															
SYNTHES 5.0 SCREW  458.956	278	RC	C1713	CPT				Both			754.16	339.37	339.37	678.74		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	558.08							Fee Schedule																													678.74							Fee Schedule																																															
SYNTHES 5.0 SCREW  458.958	278	RC	C1713	CPT				Both			808.5	363.83	363.83	727.65		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	598.29							Fee Schedule																													727.65							Fee Schedule																																															
SYNTHES 5.0 SCREW  458.960	278	RC	C1713	CPT				Both			754.16	339.37	339.37	678.74		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	558.08							Fee Schedule																													678.74							Fee Schedule																																															
SYNTHES 5.0MM POSITION. PIN #02.231.022S	278	RC	C1713	CPT				Both			1003.8	451.71	451.71	903.42		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	742.81							Fee Schedule																													903.42							Fee Schedule																																															
SYNTHES 6 HOLE PLATE 222.656	278	RC	C1713	CPT				Both			6872.25	3092.51	3092.51	6185.03		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	5085.47							Fee Schedule																													6185.03							Fee Schedule																																															
SYNTHES 6 HOLE PLATE 222.657	278	RC	C1713	CPT				Both			5823.3	2620.49	2620.49	5240.97		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	4309.24							Fee Schedule																													5240.97							Fee Schedule																																															
SYNTHES 7 HOLE PLATE 241.971	278	RC	C1713	CPT				Both			1128.75	507.94	507.94	1015.88		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	835.28							Fee Schedule																													1015.88							Fee Schedule																																															
SYNTHES 7.3 CANN SCREW 32MM 209.870	278	RC	C1713	CPT				Both			1314	591.3	591.3	1182.6		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	972.36							Fee Schedule																													1182.6							Fee Schedule																																															
SYNTHES AUTOCLAVABE OIL 519.97	272	RC						Both			141.75	63.79	63.79	127.58	92.14							Fee Schedule		104.9							Fee Schedule																													127.58							Fee Schedule																																															
SYNTHES BROAD PLATE 226.561	278	RC	C1713	CPT				Both			1304.1	586.85	586.85	1173.69		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	965.03							Fee Schedule																													1173.69							Fee Schedule																																															
SYNTHES BROAD PLATE 226.601	278	RC	C1713	CPT				Both			1971.9	887.36	887.36	1774.71		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1459.21							Fee Schedule																													1774.71							Fee Schedule																																															
SYNTHES CALCANEAL PLATE 02.211.404	278	RC	C1713	CPT				Both			4147.5	1866.38	1866.38	3732.75		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	3069.15							Fee Schedule																													3732.75							Fee Schedule																																															
SYNTHES CALCANEAL PLATE 64MM 02.211.403	278	RC	C1713	CPT				Both			4121.25	1854.56	1854.56	3709.13		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	3049.73							Fee Schedule																													3709.13							Fee Schedule																																															
SYNTHES CANCELL. SCREW 4.0X55MM 207.055	278	RC	C1713	CPT				Both			90	40.5	40.5	81		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	66.6							Fee Schedule																													81							Fee Schedule																																															
SYNTHES CANCELL. SCREW 4.0X60MM 207.060	278	RC	C1713	CPT				Both			90	40.5	40.5	81		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	66.6							Fee Schedule																													81							Fee Schedule																																															
SYNTHES CANN. SCREW 5.0 02.231.620	278	RC	C1713	CPT				Both			1105.65	497.54	497.54	995.09		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	818.18							Fee Schedule																													995.09							Fee Schedule																																															
SYNTHES CANN. SCREW ST 4.0X64MM 207.664	278	RC	C1713	CPT				Both			927.15	417.22	417.22	834.44		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	686.09							Fee Schedule																													834.44							Fee Schedule																																															
SYNTHES CANN. SCREW ST 4.0X68MM 207.668	278	RC	C1713	CPT				Both			927.15	417.22	417.22	834.44		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	686.09							Fee Schedule																													834.44							Fee Schedule																																															
SYNTHES CANN. SCREW ST 4.0X72MM 207.672	278	RC	C1713	CPT				Both			780	351	351	702		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	577.2							Fee Schedule																													702							Fee Schedule																																															
SYNTHES CARBIDE DRILL BIT 4MM 309.004S	272	RC						Both			1057.35	475.81	475.81	951.62	687.28							Fee Schedule		782.44							Fee Schedule																													951.62							Fee Schedule																																															
SYNTHES CARBIDE DRILL BIT 6MM 309.006S	272	RC						Both			1205.4	542.43	542.43	1084.86	783.51							Fee Schedule		892							Fee Schedule																													1084.86							Fee Schedule																																															
SYNTHES CONICAL SCREW 02.240.256	278	RC	C1713	CPT				Both			635.25	285.86	285.86	571.73		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	470.09							Fee Schedule																													571.73							Fee Schedule																																															
SYNTHES CONICAL SCREW 02.240.280	278	RC	C1713	CPT				Both			635.25	285.86	285.86	571.73		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	470.09							Fee Schedule																													571.73							Fee Schedule																																															
SYNTHES CONICAL SCREWS 02.207.450	278	RC	C1713	CPT				Both			833.7	375.17	375.17	750.33		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	616.94							Fee Schedule																													750.33							Fee Schedule																																															
SYNTHES CONICAL SCREWS 02.207.455	278	RC	C1713	CPT				Both			833.7	375.17	375.17	750.33		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	616.94							Fee Schedule																													750.33							Fee Schedule																																															
SYNTHES CONICAL SCREWS 02.207.460	278	RC	C1713	CPT				Both			833.7	375.17	375.17	750.33		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	616.94							Fee Schedule																													750.33							Fee Schedule																																															
SYNTHES CONICAL SCREWS 02.207.465	278	RC	C1713	CPT				Both			833.7	375.17	375.17	750.33		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	616.94							Fee Schedule																													750.33							Fee Schedule																																															
SYNTHES CONICAL SCREWS 02.207.470	278	RC	C1713	CPT				Both			950.25	427.61	427.61	855.23		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	703.19							Fee Schedule																													855.23							Fee Schedule																																															
SYNTHES CONICAL SCREWS 02.207.475	278	RC	C1713	CPT				Both			983.85	442.73	442.73	885.47		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	728.05							Fee Schedule																													885.47							Fee Schedule																																															
SYNTHES CONICAL SCREWS 02.207.480	278	RC	C1713	CPT				Both			870.45	391.7	391.7	783.41		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	644.13							Fee Schedule																													783.41							Fee Schedule																																															
SYNTHES CONICAL SCREWS 02.207.485	278	RC	C1713	CPT				Both			833.7	375.17	375.17	750.33		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	616.94							Fee Schedule																													750.33							Fee Schedule																																															
SYNTHES CONICAL SCREWS 02.207.490	278	RC	C1713	CPT				Both			833.7	375.17	375.17	750.33		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	616.94							Fee Schedule																													750.33							Fee Schedule																																															
SYNTHES CONICAL SCREWS 02.207.495	278	RC	C1713	CPT				Both			833.7	375.17	375.17	750.33		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	616.94							Fee Schedule																													750.33							Fee Schedule																																															
SYNTHES CORTEX SCREW 202.894	278	RC	C1713	CPT				Both			172.94	77.82	77.82	155.65		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	127.98							Fee Schedule																													155.65							Fee Schedule																																															
SYNTHES CORTEX SCREW 202.898	278	RC	C1713	CPT				Both			172.94	77.82	77.82	155.65		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	127.98							Fee Schedule																													155.65							Fee Schedule																																															
SYNTHES CORTEX SCREW 214.862	278	RC	C1713	CPT				Both			75.6	34.02	34.02	68.04		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	55.94							Fee Schedule																													68.04							Fee Schedule																																															
SYNTHES CORTEX SCREW 214.864	278	RC	C1713	CPT				Both			75.6	34.02	34.02	68.04		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	55.94							Fee Schedule																													68.04							Fee Schedule																																															
SYNTHES CORTEX SCREW 3.5X42MM 204.842	278	RC	C1713	CPT				Both			117	52.65	52.65	105.3		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	86.58							Fee Schedule																													105.3							Fee Schedule																																															
SYNTHES CORTEX SCREW 3.5X46MM 204.846	278	RC	C1713	CPT				Both			172	77.4	77.4	154.8		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	127.28							Fee Schedule																													154.8							Fee Schedule																																															
SYNTHES CURVED PLATE 02.124.407	278	RC	C1713	CPT				Both			7446.6	3350.97	3350.97	6701.94		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	5510.48							Fee Schedule																													6701.94							Fee Schedule																																															
SYNTHES CURVED PLATE 02.124.416	278	RC	C1713	CPT				Both			8828.4	3972.78	3972.78	7945.56		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	6533.02							Fee Schedule																													7945.56							Fee Schedule																																															
SYNTHES CURVED PLATE 6 HOLE 02.124.406	278	RC	C1713	CPT				Both			6510	2929.5	2929.5	5859		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	4817.4							Fee Schedule																													5859							Fee Schedule																																															
SYNTHES DBX PUTTY 5CC 038050	278	RC	C9356	CPT				Both			2684.85	1208.18	1208.18	2416.37		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1986.79							Fee Schedule																													2416.37							Fee Schedule																																															
SYNTHES DHS LAG SCREW 85MM 280.850	278	RC	C1713	CPT				Both			1570.8	706.86	706.86	1413.72		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1162.39							Fee Schedule																													1413.72							Fee Schedule																																															
SYNTHES DISTAL RADIUS PLATE #442.501	278	RC	C1713	CPT				Both			1360.8	612.36	612.36	1224.72		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1006.99							Fee Schedule																													1224.72							Fee Schedule																																															
SYNTHES DRILL BIT #310.23	272	RC						Both			426	191.7	191.7	383.4	276.9							Fee Schedule		315.24							Fee Schedule																													383.4							Fee Schedule																																															
SYNTHES DRILL BIT 13.0MM 351.27	272	RC						Both			2236.5	1006.43	1006.43	2012.85	1453.73							Fee Schedule		1655.01							Fee Schedule																													2012.85							Fee Schedule																																															
SYNTHES DRILL BIT 145MM # 03.010.104	270	RC						Both			837	376.65	376.65	753.3	544.05							Fee Schedule		619.38							Fee Schedule																													753.3							Fee Schedule																																															
SYNTHES DRILL BIT 2.0MM #310.21	270	RC						Both			426	191.7	191.7	383.4	276.9							Fee Schedule		315.24							Fee Schedule																													383.4							Fee Schedule																																															
SYNTHES DRILL BIT 2.0MM 323.062  MEDLINE	270	RC						Both			258	116.1	116.1	232.2	167.7							Fee Schedule		190.92							Fee Schedule																													232.2							Fee Schedule																																															
SYNTHES DRILL BIT 310.25	270	RC						Both			320	144	144	288	208							Fee Schedule		236.8							Fee Schedule																													288							Fee Schedule																																															
SYNTHES DRILL BIT 310.35	270	RC						Both			344	154.8	154.8	309.6	223.6							Fee Schedule		254.56							Fee Schedule																													309.6							Fee Schedule																																															
SYNTHES DRILL BIT 330MM # 03.010.061	272	RC						Both			928	417.6	417.6	835.2	603.2							Fee Schedule		686.72							Fee Schedule																													835.2							Fee Schedule																																															
SYNTHES DRILL BIT 4.0 257.407	272	RC						Both			357	160.65	160.65	321.3	232.05							Fee Schedule		264.18							Fee Schedule																													321.3							Fee Schedule																																															
SYNTHES DRILL BIT DEPTH GAUGE 03.010.428	270	RC						Both			5076	2284.2	2284.2	4568.4	3299.4							Fee Schedule		3756.24							Fee Schedule																													4568.4							Fee Schedule																																															
SYNTHES DRILL BIT LG. 190MM # 03.010.036	270	RC						Both			2055.9	925.16	925.16	1850.31	1336.34							Fee Schedule		1521.37							Fee Schedule																													1850.31							Fee Schedule																																															
SYNTHES DRILL SLEEVE 532.004	270	RC						Both			584.85	263.18	263.18	526.37	380.15							Fee Schedule		432.79							Fee Schedule																													526.37							Fee Schedule																																															
SYNTHES FLEXIBLE SHAFT 352-040	278	RC	C1713	CPT				Both			7802.55	3511.15	3511.15	7022.3		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	5773.89							Fee Schedule																													7022.3							Fee Schedule																																															
SYNTHES FUSION PLATE 02.110.151	278	RC	C1713	CPT				Both			5927.25	2667.26	2667.26	5334.53		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	4386.17							Fee Schedule																													5334.53							Fee Schedule																																															
SYNTHES GUIDEWIRE 2.0  292.652	272	RC	C1769	CPT				Both			182.7	82.22	82.22	164.43	154.26							Fee Schedule		135.2							Fee Schedule																													164.43							Fee Schedule																																															
SYNTHES GUIDEWIRE 2.5  03.120.026	272	RC	C1769	CPT				Both			317.1	142.7	142.7	285.39	154.26							Fee Schedule		234.65							Fee Schedule																													285.39							Fee Schedule																																															
SYNTHES HELICAL BLADE 100MM #04.038.400	278	RC	C1713	CPT				Both			3092	1391.4	1391.4	2782.8		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	2288.08							Fee Schedule																													2782.8							Fee Schedule																																															
SYNTHES HELICAL BLADE 105MM #04.038.405	278	RC	C1713	CPT				Both			3247	1461.15	1461.15	2922.3		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	2402.78							Fee Schedule																													2922.3							Fee Schedule																																															
SYNTHES HELICAL BLADE 85MM 04.038.385S	278	RC	C1713	CPT				Both			3402	1530.9	1530.9	3061.8		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	2517.48							Fee Schedule																													3061.8							Fee Schedule																																															
SYNTHES HUMERAL PLATE 02.123.023	278	RC	C1713	CPT				Both			6116.25	2752.31	2752.31	5504.63		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	4526.03							Fee Schedule																													5504.63							Fee Schedule																																															
SYNTHES LCP 2.4MM 02.111.740	278	RC	C1713	CPT				Both			3340.05	1503.02	1503.02	3006.05		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	2471.64							Fee Schedule																													3006.05							Fee Schedule																																															
SYNTHES LCP CLAVICLE  02.112.013	278	RC	C1713	CPT				Both			2957.85	1331.03	1331.03	2662.07		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	2188.81							Fee Schedule																													2662.07							Fee Schedule																																															
SYNTHES LCP CLAVICLE 3.5MM 02.112.009	278	RC	C1713	CPT				Both			2847.6	1281.42	1281.42	2562.84		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	2107.22							Fee Schedule																													2562.84							Fee Schedule																																															
SYNTHES LCP HOOK PLATE 241.075S	278	RC	C1713	CPT				Both			3896.55	1753.45	1753.45	3506.9		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	2883.45							Fee Schedule																													3506.9							Fee Schedule																																															
SYNTHES LCP RADIUS 02.110.011	278	RC	C1713	CPT				Both			5180.7	2331.32	2331.32	4662.63		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	3833.72							Fee Schedule																													4662.63							Fee Schedule																																															
SYNTHES LOCK SCREW 02.231.010	278	RC	C1713	CPT				Both			1145.55	515.5	515.5	1031		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	847.71							Fee Schedule																													1031							Fee Schedule																																															
SYNTHES LOCK SCREW 02.231.012	278	RC	C1713	CPT				Both			1145.55	515.5	515.5	1031		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	847.71							Fee Schedule																													1031							Fee Schedule																																															
SYNTHES LOCK SCREW 02.231.220	278	RC	C1713	CPT				Both			711.9	320.36	320.36	640.71		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	526.81							Fee Schedule																													640.71							Fee Schedule																																															
SYNTHES LOCK SCREW 02.231.226	278	RC	C1713	CPT				Both			816.9	367.61	367.61	735.21		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	604.51							Fee Schedule																													735.21							Fee Schedule																																															
SYNTHES LOCK SCREW 02.231.238	278	RC	C1713	CPT				Both			816.9	367.61	367.61	735.21		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	604.51							Fee Schedule																													735.21							Fee Schedule																																															
SYNTHES LOCK SCREW 02.231.240	278	RC	C1713	CPT				Both			816.9	367.61	367.61	735.21		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	604.51							Fee Schedule																													735.21							Fee Schedule																																															
SYNTHES LOCK SCREW 02.231.250	278	RC	C1713	CPT				Both			816.9	367.61	367.61	735.21		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	604.51							Fee Schedule																													735.21							Fee Schedule																																															
SYNTHES LOCK SCREW 02.231.255	278	RC	C1713	CPT				Both			711.9	320.36	320.36	640.71		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	526.81							Fee Schedule																													640.71							Fee Schedule																																															
SYNTHES LOCK SCREW 02.231.260	278	RC	C1713	CPT				Both			816.9	367.61	367.61	735.21		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	604.51							Fee Schedule																													735.21							Fee Schedule																																															
SYNTHES LOCK SCREW 02.231.270	278	RC	C1713	CPT				Both			711.9	320.36	320.36	640.71		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	526.81							Fee Schedule																													640.71							Fee Schedule																																															
SYNTHES LOCK SCREW 02.231.275	278	RC	C1713	CPT				Both			816.9	367.61	367.61	735.21		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	604.51							Fee Schedule																													735.21							Fee Schedule																																															
SYNTHES LOCK. SCREW 5.0MM NS 04.005.516	278	RC	C1713	CPT				Both			891	400.95	400.95	801.9		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	659.34							Fee Schedule																													801.9							Fee Schedule																																															
SYNTHES LOCK. SCREW 5.0MM NS 04.005.518	278	RC	C1713	CPT				Both			891	400.95	400.95	801.9		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	659.34							Fee Schedule																													801.9							Fee Schedule																																															
SYNTHES LOCK. SCREW 5.0MM NS 04.005.520	278	RC	C1713	CPT				Both			891	400.95	400.95	801.9		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	659.34							Fee Schedule																													801.9							Fee Schedule																																															
SYNTHES LOCK. SCREW 5.0MM NS 04.005.522	278	RC	C1713	CPT				Both			885	398.25	398.25	796.5		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	654.9							Fee Schedule																													796.5							Fee Schedule																																															
SYNTHES LOCK. SCREW 5.0MM NS 04.005.524	278	RC	C1713	CPT				Both			885	398.25	398.25	796.5		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	654.9							Fee Schedule																													796.5							Fee Schedule																																															
SYNTHES LOCK. SCREW 5.0MM NS 04.005.526	278	RC	C1713	CPT				Both			885	398.25	398.25	796.5		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	654.9							Fee Schedule																													796.5							Fee Schedule																																															
SYNTHES LOCK. SCREW 5.0MM NS 04.005.528	278	RC	C1713	CPT				Both			885	398.25	398.25	796.5		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	654.9							Fee Schedule																													796.5							Fee Schedule																																															
SYNTHES LOCK. SCREW 5.0MM NS 04.005.530	278	RC	C1713	CPT				Both			885	398.25	398.25	796.5		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	654.9							Fee Schedule																													796.5							Fee Schedule																																															
SYNTHES LOCK. SCREW 5.0MM NS 04.005.534	278	RC	C1713	CPT				Both			885	398.25	398.25	796.5		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	654.9							Fee Schedule																													796.5							Fee Schedule																																															
SYNTHES LOCK. SCREW 5.0MM NS 04.005.536	278	RC	C1713	CPT				Both			891	400.95	400.95	801.9		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	659.34							Fee Schedule																													801.9							Fee Schedule																																															
SYNTHES LOCK. SCREW 5.0MM NS 04.005.538	278	RC	C1713	CPT				Both			891	400.95	400.95	801.9		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	659.34							Fee Schedule																													801.9							Fee Schedule																																															
SYNTHES LOCK. SCREW 5.0MM NS 04.005.542	278	RC	C1713	CPT				Both			891	400.95	400.95	801.9		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	659.34							Fee Schedule																													801.9							Fee Schedule																																															
SYNTHES LOCK. SCREW 5.0MM NS 04.005.544	278	RC	C1713	CPT				Both			891	400.95	400.95	801.9		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	659.34							Fee Schedule																													801.9							Fee Schedule																																															
SYNTHES LOCK. SCREW 5.0MM NS 04.005.546	278	RC	C1713	CPT				Both			891	400.95	400.95	801.9		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	659.34							Fee Schedule																													801.9							Fee Schedule																																															
SYNTHES LOCK. SCREW 5.0MM NS 04.005.548	278	RC	C1713	CPT				Both			843	379.35	379.35	758.7		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	623.82							Fee Schedule																													758.7							Fee Schedule																																															
SYNTHES LOCK. SCREW 5.0MM NS 04.005.550	278	RC	C1713	CPT				Both			891	400.95	400.95	801.9		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	659.34							Fee Schedule																													801.9							Fee Schedule																																															
SYNTHES LOCK. SCREW 5.0MM NS 04.005.554	278	RC	C1713	CPT				Both			891	400.95	400.95	801.9		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	659.34							Fee Schedule																													801.9							Fee Schedule																																															
SYNTHES LOCK. SCREW 5.0MM NS 04.005.558	278	RC	C1713	CPT				Both			891	400.95	400.95	801.9		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	659.34							Fee Schedule																													801.9							Fee Schedule																																															
SYNTHES LOCK. SCREW 5.0MM NS 04.005.562	278	RC	C1713	CPT				Both			891	400.95	400.95	801.9		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	659.34							Fee Schedule																													801.9							Fee Schedule																																															
SYNTHES LOCKING SCREW #212.122	278	RC	C1713	CPT				Both			567	255.15	255.15	510.3		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	419.58							Fee Schedule																													510.3							Fee Schedule																																															
SYNTHES LOCKING SCREW 02.211.030	278	RC	C1713	CPT				Both			556.5	250.43	250.43	500.85		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	411.81							Fee Schedule																													500.85							Fee Schedule																																															
SYNTHES LOCKING SCREW 02.211.040	278	RC	C1713	CPT				Both			556.5	250.43	250.43	500.85		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	411.81							Fee Schedule																													500.85							Fee Schedule																																															
SYNTHES LOCKING SCREW 02.211.042	278	RC	C1713	CPT				Both			556.5	250.43	250.43	500.85		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	411.81							Fee Schedule																													500.85							Fee Schedule																																															
SYNTHES LOCKING SCREW 02.211.044	278	RC	C1713	CPT				Both			556.5	250.43	250.43	500.85		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	411.81							Fee Schedule																													500.85							Fee Schedule																																															
SYNTHES LOCKING SCREW 02.240.036	278	RC	C1713	CPT				Both			799.05	359.57	359.57	719.15		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	591.3							Fee Schedule																													719.15							Fee Schedule																																															
SYNTHES LOCKING SCREW 02.240.038	278	RC	C1713	CPT				Both			799.05	359.57	359.57	719.15		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	591.3							Fee Schedule																													719.15							Fee Schedule																																															
SYNTHES LOCKING SCREW 02.240.042	278	RC	C1713	CPT				Both			799.05	359.57	359.57	719.15		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	591.3							Fee Schedule																													719.15							Fee Schedule																																															
SYNTHES LOCKING SCREW 02.240.048	278	RC	C1713	CPT				Both			969	436.05	436.05	872.1		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	717.06							Fee Schedule																													872.1							Fee Schedule																																															
SYNTHES LOCKING SCREW 02.240.050	278	RC	C1713	CPT				Both			855.75	385.09	385.09	770.18		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	633.26							Fee Schedule																													770.18							Fee Schedule																																															
SYNTHES LOCKING SCREW 02.240.054	278	RC	C1713	CPT				Both			969	436.05	436.05	872.1		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	717.06							Fee Schedule																													872.1							Fee Schedule																																															
SYNTHES LOCKING SCREW 02.240.058	278	RC	C1713	CPT				Both			855.75	385.09	385.09	770.18		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	633.26							Fee Schedule																													770.18							Fee Schedule																																															
SYNTHES LOCKING SCREW 02.240.060	278	RC	C1713	CPT				Both			855.75	385.09	385.09	770.18		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	633.26							Fee Schedule																													770.18							Fee Schedule																																															
SYNTHES LOCKING SCREW 02.240.065	278	RC	C1713	CPT				Both			969	436.05	436.05	872.1		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	717.06							Fee Schedule																													872.1							Fee Schedule																																															
SYNTHES LOCKING SCREW 02.240.070	278	RC	C1713	CPT				Both			969	436.05	436.05	872.1		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	717.06							Fee Schedule																													872.1							Fee Schedule																																															
SYNTHES LOCKING SCREW 02.240.075	278	RC	C1713	CPT				Both			745.5	335.48	335.48	670.95		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	551.67							Fee Schedule																													670.95							Fee Schedule																																															
SYNTHES LOCKING SCREW 02.240.080	278	RC	C1713	CPT				Both			856.17	385.28	385.28	770.55		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	633.57							Fee Schedule																													770.55							Fee Schedule																																															
SYNTHES LOCKING SCREW 04.004.008S	278	RC	C1713	CPT				Both			685.65	308.54	308.54	617.09		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	507.38							Fee Schedule																													617.09							Fee Schedule																																															
SYNTHES LOCKING SCREW 04.005.416S	278	RC	C1713	CPT				Both			567	255.15	255.15	510.3		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	419.58							Fee Schedule																													510.3							Fee Schedule																																															
SYNTHES LOCKING SCREW 04.005.436S	278	RC	C1713	CPT				Both			567	255.15	255.15	510.3		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	419.58							Fee Schedule																													510.3							Fee Schedule																																															
SYNTHES LOCKING SCREW 212.814	278	RC	C1713	CPT				Both			363.3	163.49	163.49	326.97		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	268.84							Fee Schedule																													326.97							Fee Schedule																																															
SYNTHES LOCKING SCREW 222.572	278	RC	C1713	CPT				Both			793.8	357.21	357.21	714.42		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	587.41							Fee Schedule																													714.42							Fee Schedule																																															
SYNTHES LOCKING SCREW 222.590	278	RC	C1713	CPT				Both			378	170.1	170.1	340.2		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	279.72							Fee Schedule																													340.2							Fee Schedule																																															
SYNTHES LOCKING SCREW 3.5MM #02.212.056	278	RC	C1713	CPT				Both			567	255.15	255.15	510.3		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	419.58							Fee Schedule																													510.3							Fee Schedule																																															
SYNTHES LOCKING SCREWS 02.205.025	278	RC	C1713	CPT				Both			878.85	395.48	395.48	790.97		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	650.35							Fee Schedule																													790.97							Fee Schedule																																															
SYNTHES LOCKING SCREWS 02.205.030	278	RC	C1713	CPT				Both			630	283.5	283.5	567		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	466.2							Fee Schedule																													567							Fee Schedule																																															
SYNTHES LOCKING SCREWS 02.205.035	278	RC	C1713	CPT				Both			652.05	293.42	293.42	586.85		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	482.52							Fee Schedule																													586.85							Fee Schedule																																															
SYNTHES LOCKING SCREWS 02.205.040	278	RC	C1713	CPT				Both			630	283.5	283.5	567		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	466.2							Fee Schedule																													567							Fee Schedule																																															
SYNTHES LOCKING SCREWS 02.205.045	278	RC	C1713	CPT				Both			672	302.4	302.4	604.8		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	497.28							Fee Schedule																													604.8							Fee Schedule																																															
SYNTHES LOCKING SCREWS 02.205.050	278	RC	C1713	CPT				Both			878.85	395.48	395.48	790.97		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	650.35							Fee Schedule																													790.97							Fee Schedule																																															
SYNTHES LOCKING SCREWS 02.205.055	278	RC	C1713	CPT				Both			1619.1	728.6	728.6	1457.19		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1198.13							Fee Schedule																													1457.19							Fee Schedule																																															
SYNTHES LOCKING SCREWS 02.205.060	278	RC	C1713	CPT				Both			878.85	395.48	395.48	790.97		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	650.35							Fee Schedule																													790.97							Fee Schedule																																															
SYNTHES LOCKING SCREWS 02.205.065	278	RC	C1713	CPT				Both			765.45	344.45	344.45	688.91		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	566.43							Fee Schedule																													688.91							Fee Schedule																																															
SYNTHES LOCKING SCREWS 02.205.070	278	RC	C1713	CPT				Both			630	283.5	283.5	567		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	466.2							Fee Schedule																													567							Fee Schedule																																															
SYNTHES LOCKING SCREWS 02.205.075	278	RC	C1713	CPT				Both			765.45	344.45	344.45	688.91		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	566.43							Fee Schedule																													688.91							Fee Schedule																																															
SYNTHES LOCKING SCREWS 02.205.080	278	RC	C1713	CPT				Both			656.25	295.31	295.31	590.63		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	485.63							Fee Schedule																													590.63							Fee Schedule																																															
SYNTHES LOCKING SCREWS 02.205.085	278	RC	C1713	CPT				Both			630	283.5	283.5	567		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	466.2							Fee Schedule																													567							Fee Schedule																																															
SYNTHES LOCKING SCREWS 02.205.090	278	RC	C1713	CPT				Both			630	283.5	283.5	567		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	466.2							Fee Schedule																													567							Fee Schedule																																															
SYNTHES LOCKING SCREWS 02.205.095	278	RC	C1713	CPT				Both			630	283.5	283.5	567		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	466.2							Fee Schedule																													567							Fee Schedule																																															
SYNTHES LOCKING SCREWS 02.205.240	278	RC	C1713	CPT				Both			556.5	250.43	250.43	500.85		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	411.81							Fee Schedule																													500.85							Fee Schedule																																															
SYNTHES LOCKING SCREWS 02.205.245	278	RC	C1713	CPT				Both			556.5	250.43	250.43	500.85		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	411.81							Fee Schedule																													500.85							Fee Schedule																																															
SYNTHES LOCKING SCREWS 02.205.250	278	RC	C1713	CPT				Both			556.5	250.43	250.43	500.85		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	411.81							Fee Schedule																													500.85							Fee Schedule																																															
SYNTHES LOCKING SCREWS 02.205.255	278	RC	C1713	CPT				Both			556.5	250.43	250.43	500.85		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	411.81							Fee Schedule																													500.85							Fee Schedule																																															
SYNTHES LOCKING SCREWS 02.205.260	278	RC	C1713	CPT				Both			556.5	250.43	250.43	500.85		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	411.81							Fee Schedule																													500.85							Fee Schedule																																															
SYNTHES LOCKING SCREWS 02.205.260	278	RC	C1713	CPT				Both			556.5	250.43	250.43	500.85		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	411.81							Fee Schedule																													500.85							Fee Schedule																																															
SYNTHES LOCKING SCREWS 02.205.265	278	RC	C1713	CPT				Both			556.5	250.43	250.43	500.85		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	411.81							Fee Schedule																													500.85							Fee Schedule																																															
SYNTHES LOCKING SCREWS 02.205.270	278	RC	C1713	CPT				Both			777	349.65	349.65	699.3		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	574.98							Fee Schedule																													699.3							Fee Schedule																																															
SYNTHES LOCKING SCREWS 02.205.275	278	RC	C1713	CPT				Both			677.25	304.76	304.76	609.53		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	501.17							Fee Schedule																													609.53							Fee Schedule																																															
SYNTHES LOCKING SCREWS 02.205.280	278	RC	C1713	CPT				Both			556.5	250.43	250.43	500.85		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	411.81							Fee Schedule																													500.85							Fee Schedule																																															
SYNTHES LOCKING SCREWS 02.205.285	278	RC	C1713	CPT				Both			556.5	250.43	250.43	500.85		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	411.81							Fee Schedule																													500.85							Fee Schedule																																															
SYNTHES LOCKING SCREWS 02.205.290	278	RC	C1713	CPT				Both			556.5	250.43	250.43	500.85		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	411.81							Fee Schedule																													500.85							Fee Schedule																																															
SYNTHES LOCKING SCREWS 02.205.295	278	RC	C1713	CPT				Both			556.5	250.43	250.43	500.85		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	411.81							Fee Schedule																													500.85							Fee Schedule																																															
SYNTHES LOCKING SCREWS 02.207.050	278	RC	C1713	CPT				Both			930.3	418.64	418.64	837.27		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	688.42							Fee Schedule																													837.27							Fee Schedule																																															
SYNTHES LOCKING SCREWS 02.207.055	278	RC	C1713	CPT				Both			930.3	418.64	418.64	837.27		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	688.42							Fee Schedule																													837.27							Fee Schedule																																															
SYNTHES LOCKING SCREWS 02.207.060	278	RC	C1713	CPT				Both			930.3	418.64	418.64	837.27		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	688.42							Fee Schedule																													837.27							Fee Schedule																																															
SYNTHES LOCKING SCREWS 02.207.065	278	RC	C1713	CPT				Both			930.3	418.64	418.64	837.27		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	688.42							Fee Schedule																													837.27							Fee Schedule																																															
SYNTHES LOCKING SCREWS 02.207.070	278	RC	C1713	CPT				Both			1102.5	496.13	496.13	992.25		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	815.85							Fee Schedule																													992.25							Fee Schedule																																															
SYNTHES LOCKING SCREWS 02.207.075	278	RC	C1713	CPT				Both			264.6	119.07	119.07	238.14		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	195.8							Fee Schedule																													238.14							Fee Schedule																																															
SYNTHES LOCKING SCREWS 02.207.080	278	RC	C1713	CPT				Both			974.4	438.48	438.48	876.96		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	721.06							Fee Schedule																													876.96							Fee Schedule																																															
SYNTHES LOCKING SCREWS 02.207.085	278	RC	C1713	CPT				Both			264.6	119.07	119.07	238.14		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	195.8							Fee Schedule																													238.14							Fee Schedule																																															
SYNTHES LOCKING SCREWS 02.207.090	278	RC	C1713	CPT				Both			930.3	418.64	418.64	837.27		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	688.42							Fee Schedule																													837.27							Fee Schedule																																															
SYNTHES LOCKING SCREWS 02.207.095	278	RC	C1713	CPT				Both			930.3	418.64	418.64	837.27		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	688.42							Fee Schedule																													837.27							Fee Schedule																																															
SYNTHES LOCKING SCREWS 02.210.116	278	RC	C1713	CPT				Both			431.55	194.2	194.2	388.4		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	319.35							Fee Schedule																													388.4							Fee Schedule																																															
SYNTHES LOCKING SCREWS 02.210.118	278	RC	C1713	CPT				Both			431.55	194.2	194.2	388.4		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	319.35							Fee Schedule																													388.4							Fee Schedule																																															
SYNTHES LOCKING SCREWS 02.210.120	278	RC	C1713	CPT				Both			431.55	194.2	194.2	388.4		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	319.35							Fee Schedule																													388.4							Fee Schedule																																															
SYNTHES METAPH. S.T. SCREW 02.118.516	278	RC	C1713	CPT				Both			205.8	92.61	92.61	185.22		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	152.29							Fee Schedule																													185.22							Fee Schedule																																															
SYNTHES METAPH. S.T. SCREW 02.118.522	278	RC	C1713	CPT				Both			205.8	92.61	92.61	185.22		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	152.29							Fee Schedule																													185.22							Fee Schedule																																															
SYNTHES METAPH. S.T. SCREW 02.118.538	278	RC	C1713	CPT				Both			178.5	80.33	80.33	160.65		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	132.09							Fee Schedule																													160.65							Fee Schedule																																															
SYNTHES NORIAN BONE FILLER 07.707.010S	278	RC	C1763	CPT				Both			10614.45	4776.5	4776.5	9553.01		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	7854.69							Fee Schedule																													9553.01							Fee Schedule																																															
SYNTHES PERCUTANEOUS DRILL BIT #324.213	270	RC						Both			862.05	387.92	387.92	775.85	560.33							Fee Schedule		637.92							Fee Schedule																													775.85							Fee Schedule																																															
SYNTHES PERCUTANEOUS DRILL BIT 324.214	270	RC						Both			675.15	303.82	303.82	607.64	438.85							Fee Schedule		499.61							Fee Schedule																													607.64							Fee Schedule																																															
SYNTHES PLATE 245.101	278	RC	C1713	CPT				Both			1520.4	684.18	684.18	1368.36		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1125.1							Fee Schedule																													1368.36							Fee Schedule																																															
SYNTHES PLATE 245.121	278	RC	C1713	CPT				Both			1656.9	745.61	745.61	1491.21		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1226.11							Fee Schedule																													1491.21							Fee Schedule																																															
SYNTHES PLATE 3.5MM 239.955	278	RC	C1713	CPT				Both			7155	3219.75	3219.75	6439.5		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	5294.7							Fee Schedule																													6439.5							Fee Schedule																																															
SYNTHES PROXIMAL PLATE 02.107.002	278	RC	C1713	CPT				Both			3260.25	1467.11	1467.11	2934.23		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	2412.59							Fee Schedule																													2934.23							Fee Schedule																																															
SYNTHES PROXIMAL PLATE 02.107.102	278	RC	C1713	CPT				Both			4116	1852.2	1852.2	3704.4		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	3045.84							Fee Schedule																													3704.4							Fee Schedule																																															
SYNTHES REAMING ROD 359.083S	272	RC						Both			581.7	261.77	261.77	523.53	378.11							Fee Schedule		430.46							Fee Schedule																													523.53							Fee Schedule																																															
SYNTHES SCHANZ SCREW 60MM  494.784	278	RC	C1713	CPT				Both			842.1	378.95	378.95	757.89		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	623.15							Fee Schedule																													757.89							Fee Schedule																																															
SYNTHES SCHANZ SCREW 60MM  494.785	278	RC	C1713	CPT				Both			842.1	378.95	378.95	757.89		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	623.15							Fee Schedule																													757.89							Fee Schedule																																															
SYNTHES SCREW # 207.652	278	RC	C1713	CPT				Both			927.15	417.22	417.22	834.44		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	686.09							Fee Schedule																													834.44							Fee Schedule																																															
SYNTHES SCREW # 207.658	278	RC	C1713	CPT				Both			927.15	417.22	417.22	834.44		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	686.09							Fee Schedule																													834.44							Fee Schedule																																															
SYNTHES SCREW # 207.660	278	RC	C1713	CPT				Both			927.15	417.22	417.22	834.44		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	686.09							Fee Schedule																													834.44							Fee Schedule																																															
SYNTHES SCREW # 212.120	278	RC	C1713	CPT				Both			567	255.15	255.15	510.3		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	419.58							Fee Schedule																													510.3							Fee Schedule																																															
SYNTHES SCREW 02.118.510	278	RC	C1713	CPT				Both			205.54	92.49	92.49	184.99		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	152.1							Fee Schedule																													184.99							Fee Schedule																																															
SYNTHES SCREW 02.118.512	278	RC	C1713	CPT				Both			500.85	225.38	225.38	450.77		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	370.63							Fee Schedule																													450.77							Fee Schedule																																															
SYNTHES SCREW 02.118.514	278	RC	C1713	CPT				Both			205.54	92.49	92.49	184.99		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	152.1							Fee Schedule																													184.99							Fee Schedule																																															
SYNTHES SCREW 02.118.518	278	RC	C1713	CPT				Both			234	105.3	105.3	210.6		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	173.16							Fee Schedule																													210.6							Fee Schedule																																															
SYNTHES SCREW 02.118.520	278	RC	C1713	CPT				Both			205.54	92.49	92.49	184.99		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	152.1							Fee Schedule																													184.99							Fee Schedule																																															
SYNTHES SCREW 02.118.524	278	RC	C1713	CPT				Both			205.54	92.49	92.49	184.99		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	152.1							Fee Schedule																													184.99							Fee Schedule																																															
SYNTHES SCREW 02.118.526	278	RC	C1713	CPT				Both			205.54	92.49	92.49	184.99		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	152.1							Fee Schedule																													184.99							Fee Schedule																																															
SYNTHES SCREW 02.118.528	278	RC	C1713	CPT				Both			205.54	92.49	92.49	184.99		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	152.1							Fee Schedule																													184.99							Fee Schedule																																															
SYNTHES SCREW 02.118.542	278	RC	C1713	CPT				Both			205.54	92.49	92.49	184.99		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	152.1							Fee Schedule																													184.99							Fee Schedule																																															
SYNTHES SCREW 02.118.544	278	RC	C1713	CPT				Both			205.54	92.49	92.49	184.99		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	152.1							Fee Schedule																													184.99							Fee Schedule																																															
SYNTHES SCREW 02.118.546	278	RC	C1713	CPT				Both			205.54	92.49	92.49	184.99		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	152.1							Fee Schedule																													184.99							Fee Schedule																																															
SYNTHES SCREW 02.118.548	278	RC	C1713	CPT				Both			205.54	92.49	92.49	184.99		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	152.1							Fee Schedule																													184.99							Fee Schedule																																															
SYNTHES SCREW 02.118.550	278	RC	C1713	CPT				Both			205.54	92.49	92.49	184.99		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	152.1							Fee Schedule																													184.99							Fee Schedule																																															
SYNTHES SCREW 02.118.552	278	RC	C1713	CPT				Both			205.54	92.49	92.49	184.99		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	152.1							Fee Schedule																													184.99							Fee Schedule																																															
SYNTHES SCREW 02.118.554	278	RC	C1713	CPT				Both			205.54	92.49	92.49	184.99		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	152.1							Fee Schedule																													184.99							Fee Schedule																																															
SYNTHES SCREW 02.118.556	278	RC	C1713	CPT				Both			205.54	92.49	92.49	184.99		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	152.1							Fee Schedule																													184.99							Fee Schedule																																															
SYNTHES SCREW 02.118.558	278	RC	C1713	CPT				Both			205.54	92.49	92.49	184.99		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	152.1							Fee Schedule																													184.99							Fee Schedule																																															
SYNTHES SCREW 02.118.560	278	RC	C1713	CPT				Both			205.54	92.49	92.49	184.99		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	152.1							Fee Schedule																													184.99							Fee Schedule																																															
SYNTHES SCREW 02.127.110	278	RC	C1713	CPT				Both			677.78	305	305	610		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	501.56							Fee Schedule																													610							Fee Schedule																																															
SYNTHES SCREW 02.127.112	278	RC	C1713	CPT				Both			677.78	305	305	610		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	501.56							Fee Schedule																													610							Fee Schedule																																															
SYNTHES SCREW 02.127.114	278	RC	C1713	CPT				Both			677.78	305	305	610		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	501.56							Fee Schedule																													610							Fee Schedule																																															
SYNTHES SCREW 02.127.116	278	RC	C1713	CPT				Both			677.78	305	305	610		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	501.56							Fee Schedule																													610							Fee Schedule																																															
SYNTHES SCREW 02.127.118	278	RC	C1713	CPT				Both			677.78	305	305	610		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	501.56							Fee Schedule																													610							Fee Schedule																																															
SYNTHES SCREW 02.127.120	278	RC	C1713	CPT				Both			677.78	305	305	610		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	501.56							Fee Schedule																													610							Fee Schedule																																															
SYNTHES SCREW 02.127.122	278	RC	C1713	CPT				Both			677.78	305	305	610		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	501.56							Fee Schedule																													610							Fee Schedule																																															
SYNTHES SCREW 02.127.124	278	RC	C1713	CPT				Both			677.78	305	305	610		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	501.56							Fee Schedule																													610							Fee Schedule																																															
SYNTHES SCREW 02.127.126	278	RC	C1713	CPT				Both			677.78	305	305	610		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	501.56							Fee Schedule																													610							Fee Schedule																																															
SYNTHES SCREW 02.127.128	278	RC	C1713	CPT				Both			677.78	305	305	610		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	501.56							Fee Schedule																													610							Fee Schedule																																															
SYNTHES SCREW 02.127.130	278	RC	C1713	CPT				Both			677.78	305	305	610		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	501.56							Fee Schedule																													610							Fee Schedule																																															
SYNTHES SCREW 02.127.132	278	RC	C1713	CPT				Both			677.78	305	305	610		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	501.56							Fee Schedule																													610							Fee Schedule																																															
SYNTHES SCREW 02.127.134	278	RC	C1713	CPT				Both			677.78	305	305	610		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	501.56							Fee Schedule																													610							Fee Schedule																																															
SYNTHES SCREW 02.127.136	278	RC	C1713	CPT				Both			677.78	305	305	610		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	501.56							Fee Schedule																													610							Fee Schedule																																															
SYNTHES SCREW 02.127.138	278	RC	C1713	CPT				Both			677.78	305	305	610		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	501.56							Fee Schedule																													610							Fee Schedule																																															
SYNTHES SCREW 02.127.142	278	RC	C1713	CPT				Both			677.78	305	305	610		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	501.56							Fee Schedule																													610							Fee Schedule																																															
SYNTHES SCREW 02.127.146	278	RC	C1713	CPT				Both			677.78	305	305	610		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	501.56							Fee Schedule																													610							Fee Schedule																																															
SYNTHES SCREW 02.127.148	278	RC	C1713	CPT				Both			768	345.6	345.6	691.2		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	568.32							Fee Schedule																													691.2							Fee Schedule																																															
SYNTHES SCREW 02.127.152	278	RC	C1713	CPT				Both			677.78	305	305	610		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	501.56							Fee Schedule																													610							Fee Schedule																																															
SYNTHES SCREW 02.127.156	278	RC	C1713	CPT				Both			677.78	305	305	610		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	501.56							Fee Schedule																													610							Fee Schedule																																															
SYNTHES SCREW 02.127.158	278	RC	C1713	CPT				Both			677.78	305	305	610		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	501.56							Fee Schedule																													610							Fee Schedule																																															
SYNTHES SCREW 02.200.016	278	RC	C1713	CPT				Both			92.4	41.58	41.58	83.16		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	68.38							Fee Schedule																													83.16							Fee Schedule																																															
SYNTHES SCREW 02.200.018	278	RC	C1713	CPT				Both			92.4	41.58	41.58	83.16		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	68.38							Fee Schedule																													83.16							Fee Schedule																																															
SYNTHES SCREW 02.206.210	278	RC	C1713	CPT				Both			161.7	72.77	72.77	145.53		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	119.66							Fee Schedule																													145.53							Fee Schedule																																															
SYNTHES SCREW 02.206.212	278	RC	C1713	CPT				Both			289.8	130.41	130.41	260.82		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	214.45							Fee Schedule																													260.82							Fee Schedule																																															
SYNTHES SCREW 02.206.214	278	RC	C1713	CPT				Both			161.7	72.77	72.77	145.53		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	119.66							Fee Schedule																													145.53							Fee Schedule																																															
SYNTHES SCREW 02.206.216	278	RC	C1713	CPT				Both			161.7	72.77	72.77	145.53		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	119.66							Fee Schedule																													145.53							Fee Schedule																																															
SYNTHES SCREW 02.206.218	278	RC	C1713	CPT				Both			161.7	72.77	72.77	145.53		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	119.66							Fee Schedule																													145.53							Fee Schedule																																															
SYNTHES SCREW 02.206.220	278	RC	C1713	CPT				Both			161.7	72.77	72.77	145.53		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	119.66							Fee Schedule																													145.53							Fee Schedule																																															
SYNTHES SCREW 02.206.222	278	RC	C1713	CPT				Both			161.7	72.77	72.77	145.53		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	119.66							Fee Schedule																													145.53							Fee Schedule																																															
SYNTHES SCREW 02.206.224	278	RC	C1713	CPT				Both			161.7	72.77	72.77	145.53		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	119.66							Fee Schedule																													145.53							Fee Schedule																																															
SYNTHES SCREW 02.206.226	278	RC	C1713	CPT				Both			161.7	72.77	72.77	145.53		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	119.66							Fee Schedule																													145.53							Fee Schedule																																															
SYNTHES SCREW 02.206.228	278	RC	C1713	CPT				Both			161.7	72.77	72.77	145.53		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	119.66							Fee Schedule																													145.53							Fee Schedule																																															
SYNTHES SCREW 02.206.228	278	RC	C1713	CPT				Both			161.7	72.77	72.77	145.53		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	119.66							Fee Schedule																													145.53							Fee Schedule																																															
SYNTHES SCREW 02.206.230	278	RC	C1713	CPT				Both			161.7	72.77	72.77	145.53		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	119.66							Fee Schedule																													145.53							Fee Schedule																																															
SYNTHES SCREW 02.206.232	278	RC	C1713	CPT				Both			161.7	72.77	72.77	145.53		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	119.66							Fee Schedule																													145.53							Fee Schedule																																															
SYNTHES SCREW 02.206.234	278	RC	C1713	CPT				Both			161.7	72.77	72.77	145.53		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	119.66							Fee Schedule																													145.53							Fee Schedule																																															
SYNTHES SCREW 02.206.236	278	RC	C1713	CPT				Both			161.7	72.77	72.77	145.53		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	119.66							Fee Schedule																													145.53							Fee Schedule																																															
SYNTHES SCREW 02.206.238	278	RC	C1713	CPT				Both			161.7	72.77	72.77	145.53		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	119.66							Fee Schedule																													145.53							Fee Schedule																																															
SYNTHES SCREW 02.206.240	278	RC	C1713	CPT				Both			161.7	72.77	72.77	145.53		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	119.66							Fee Schedule																													145.53							Fee Schedule																																															
SYNTHES SCREW 02.206.242	278	RC	C1713	CPT				Both			161.7	72.77	72.77	145.53		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	119.66							Fee Schedule																													145.53							Fee Schedule																																															
SYNTHES SCREW 02.206.244	278	RC	C1713	CPT				Both			161.7	72.77	72.77	145.53		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	119.66							Fee Schedule																													145.53							Fee Schedule																																															
SYNTHES SCREW 02.206.246	278	RC	C1713	CPT				Both			161.7	72.77	72.77	145.53		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	119.66							Fee Schedule																													145.53							Fee Schedule																																															
SYNTHES SCREW 02.206.248	278	RC	C1713	CPT				Both			161.7	72.77	72.77	145.53		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	119.66							Fee Schedule																													145.53							Fee Schedule																																															
SYNTHES SCREW 02.206.250	278	RC	C1713	CPT				Both			161.7	72.77	72.77	145.53		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	119.66							Fee Schedule																													145.53							Fee Schedule																																															
SYNTHES SCREW 02.206.252	278	RC	C1713	CPT				Both			161.7	72.77	72.77	145.53		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	119.66							Fee Schedule																													145.53							Fee Schedule																																															
SYNTHES SCREW 02.206.254	278	RC	C1713	CPT				Both			161.7	72.77	72.77	145.53		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	119.66							Fee Schedule																													145.53							Fee Schedule																																															
SYNTHES SCREW 02.206.256	278	RC	C1713	CPT				Both			161.7	72.77	72.77	145.53		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	119.66							Fee Schedule																													145.53							Fee Schedule																																															
SYNTHES SCREW 02.206.258	278	RC	C1713	CPT				Both			161.7	72.77	72.77	145.53		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	119.66							Fee Schedule																													145.53							Fee Schedule																																															
SYNTHES SCREW 02.206.260	278	RC	C1713	CPT				Both			161.7	72.77	72.77	145.53		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	119.66							Fee Schedule																													145.53							Fee Schedule																																															
SYNTHES SCREW 02.211.010	278	RC	C1713	CPT				Both			638.4	287.28	287.28	574.56		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	472.42							Fee Schedule																													574.56							Fee Schedule																																															
SYNTHES SCREW 02.211.012	278	RC	C1713	CPT				Both			863.1	388.4	388.4	776.79		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	638.69							Fee Schedule																													776.79							Fee Schedule																																															
SYNTHES SCREW 02.211.014	278	RC	C1713	CPT				Both			723	325.35	325.35	650.7		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	535.02							Fee Schedule																													650.7							Fee Schedule																																															
SYNTHES SCREW 02.211.016	278	RC	C1713	CPT				Both			723	325.35	325.35	650.7		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	535.02							Fee Schedule																													650.7							Fee Schedule																																															
SYNTHES SCREW 02.211.018	278	RC	C1713	CPT				Both			863.1	388.4	388.4	776.79		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	638.69							Fee Schedule																													776.79							Fee Schedule																																															
SYNTHES SCREW 02.211.020	278	RC	C1713	CPT				Both			638.4	287.28	287.28	574.56		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	472.42							Fee Schedule																													574.56							Fee Schedule																																															
SYNTHES SCREW 02.211.022	278	RC	C1713	CPT				Both			638.4	287.28	287.28	574.56		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	472.42							Fee Schedule																													574.56							Fee Schedule																																															
SYNTHES SCREW 02.211.024	278	RC	C1713	CPT				Both			504	226.8	226.8	453.6		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	372.96							Fee Schedule																													453.6							Fee Schedule																																															
SYNTHES SCREW 02.211.026	278	RC	C1713	CPT				Both			638.4	287.28	287.28	574.56		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	472.42							Fee Schedule																													574.56							Fee Schedule																																															
SYNTHES SCREW 02.211.032	278	RC	C1713	CPT				Both			638.4	287.28	287.28	574.56		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	472.42							Fee Schedule																													574.56							Fee Schedule																																															
SYNTHES SCREW 02.211.046	278	RC	C1713	CPT				Both			638.4	287.28	287.28	574.56		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	472.42							Fee Schedule																													574.56							Fee Schedule																																															
SYNTHES SCREW 02.211.048	278	RC	C1713	CPT				Both			638.4	287.28	287.28	574.56		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	472.42							Fee Schedule																													574.56							Fee Schedule																																															
SYNTHES SCREW 02.211.050	278	RC	C1713	CPT				Both			638.4	287.28	287.28	574.56		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	472.42							Fee Schedule																													574.56							Fee Schedule																																															
SYNTHES SCREW 02.211.052	278	RC	C1713	CPT				Both			638.4	287.28	287.28	574.56		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	472.42							Fee Schedule																													574.56							Fee Schedule																																															
SYNTHES SCREW 02.211.054	278	RC	C1713	CPT				Both			638.4	287.28	287.28	574.56		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	472.42							Fee Schedule																													574.56							Fee Schedule																																															
SYNTHES SCREW 02.211.056	278	RC	C1713	CPT				Both			638.4	287.28	287.28	574.56		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	472.42							Fee Schedule																													574.56							Fee Schedule																																															
SYNTHES SCREW 02.211.058	278	RC	C1713	CPT				Both			638.4	287.28	287.28	574.56		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	472.42							Fee Schedule																													574.56							Fee Schedule																																															
SYNTHES SCREW 02.211.060	278	RC	C1713	CPT				Both			638.4	287.28	287.28	574.56		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	472.42							Fee Schedule																													574.56							Fee Schedule																																															
SYNTHES SCREW 03.118.100	278	RC	C1713	CPT				Both			1355.29	609.88	609.88	1219.76		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1002.91							Fee Schedule																													1219.76							Fee Schedule																																															
SYNTHES SCREW 03.118.101	278	RC	C1713	CPT				Both			1355.29	609.88	609.88	1219.76		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1002.91							Fee Schedule																													1219.76							Fee Schedule																																															
SYNTHES SCREW 03.118.102	278	RC	C1713	CPT				Both			1355.29	609.88	609.88	1219.76		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1002.91							Fee Schedule																													1219.76							Fee Schedule																																															
SYNTHES SCREW 03.118.103	278	RC	C1713	CPT				Both			1355.29	609.88	609.88	1219.76		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1002.91							Fee Schedule																													1219.76							Fee Schedule																																															
SYNTHES SCREW 03.118.106	278	RC	C1713	CPT				Both			1355.29	609.88	609.88	1219.76		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1002.91							Fee Schedule																													1219.76							Fee Schedule																																															
SYNTHES SCREW 03.118.107	278	RC	C1713	CPT				Both			1355.29	609.88	609.88	1219.76		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1002.91							Fee Schedule																													1219.76							Fee Schedule																																															
SYNTHES SCREW 1.3 400.606	278	RC	C1713	CPT				Both			226.8	102.06	102.06	204.12		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	167.83							Fee Schedule																													204.12							Fee Schedule																																															
SYNTHES SCREW 1.3 400.607	278	RC	C1713	CPT				Both			226.8	102.06	102.06	204.12		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	167.83							Fee Schedule																													204.12							Fee Schedule																																															
SYNTHES SCREW 1.3 400.608	278	RC	C1713	CPT				Both			226.8	102.06	102.06	204.12		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	167.83							Fee Schedule																													204.12							Fee Schedule																																															
SYNTHES SCREW 1.3 400.609	278	RC	C1713	CPT				Both			226.8	102.06	102.06	204.12		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	167.83							Fee Schedule																													204.12							Fee Schedule																																															
SYNTHES SCREW 1.3 400.610	278	RC	C1713	CPT				Both			226.8	102.06	102.06	204.12		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	167.83							Fee Schedule																													204.12							Fee Schedule																																															
SYNTHES SCREW 1.3 400.611	278	RC	C1713	CPT				Both			226.8	102.06	102.06	204.12		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	167.83							Fee Schedule																													204.12							Fee Schedule																																															
SYNTHES SCREW 1.3 400.612	278	RC	C1713	CPT				Both			226.8	102.06	102.06	204.12		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	167.83							Fee Schedule																													204.12							Fee Schedule																																															
SYNTHES SCREW 40 MM SCREW	278	RC	C1713	CPT				Both			226.8	102.06	102.06	204.12		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	167.83							Fee Schedule																													204.12							Fee Schedule																																															
SYNTHES SCREW#  207.656	278	RC	C1713	CPT				Both			927.15	417.22	417.22	834.44		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	686.09							Fee Schedule																													834.44							Fee Schedule																																															
SYNTHES SELF TAP SCREW 02.211.028	278	RC	C1713	CPT				Both			638.4	287.28	287.28	574.56		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	472.42							Fee Schedule																													574.56							Fee Schedule																																															
SYNTHES SELF TAP SCREW 02.211.034	278	RC	C1713	CPT				Both			556.5	250.43	250.43	500.85		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	411.81							Fee Schedule																													500.85							Fee Schedule																																															
SYNTHES SELF TAP SCREW 02.211.036	278	RC	C1713	CPT				Both			638.4	287.28	287.28	574.56		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	472.42							Fee Schedule																													574.56							Fee Schedule																																															
SYNTHES SELF TAP SCREW 02.211.038	278	RC	C1713	CPT				Both			638.4	287.28	287.28	574.56		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	472.42							Fee Schedule																													574.56							Fee Schedule																																															
SYNTHES SELF TAPPING SCREW 02.118.530	278	RC	C1713	CPT				Both			178.5	80.33	80.33	160.65		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	132.09							Fee Schedule																													160.65							Fee Schedule																																															
SYNTHES SELF TAPPING SCREW 02.118.532	278	RC	C1713	CPT				Both			178.5	80.33	80.33	160.65		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	132.09							Fee Schedule																													160.65							Fee Schedule																																															
SYNTHES SELF TAPPING SCREW 02.118.534	278	RC	C1713	CPT				Both			178.5	80.33	80.33	160.65		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	132.09							Fee Schedule																													160.65							Fee Schedule																																															
SYNTHES SELF TAPPING SCREW 02.118.536	278	RC	C1713	CPT				Both			178.5	80.33	80.33	160.65		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	132.09							Fee Schedule																													160.65							Fee Schedule																																															
SYNTHES SELF TAPPING SCREW 02.118.540	278	RC	C1713	CPT				Both			178.5	80.33	80.33	160.65		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	132.09							Fee Schedule																													160.65							Fee Schedule																																															
SYNTHES TFN BLADE 95MM  04.038.395	278	RC	C1713	CPT				Both			3247	1461.15	1461.15	2922.3		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	2402.78							Fee Schedule																													2922.3							Fee Schedule																																															
SYNTHES TFNA BLADE 110MM 04.038.410	278	RC	C1713	CPT				Both			3247	1461.15	1461.15	2922.3		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	2402.78							Fee Schedule																													2922.3							Fee Schedule																																															
SYNTHES TFNA BLADE 115MM 04.038.415	278	RC	C1713	CPT				Both			3273	1472.85	1472.85	2945.7		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	2422.02							Fee Schedule																													2945.7							Fee Schedule																																															
SYNTHES TFNA BLADE 120MM 04.038.420	278	RC	C1713	CPT				Both			3273	1472.85	1472.85	2945.7		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	2422.02							Fee Schedule																													2945.7							Fee Schedule																																															
SYNTHES TFNA BLADE 125MM 04.038.425	278	RC	C1713	CPT				Both			3273	1472.85	1472.85	2945.7		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	2422.02							Fee Schedule																													2945.7							Fee Schedule																																															
SYNTHES TFNA BLADE 130MM 04.038.430	278	RC	C1713	CPT				Both			3273	1472.85	1472.85	2945.7		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	2422.02							Fee Schedule																													2945.7							Fee Schedule																																															
SYNTHES TFNA BLADE 70MM 04.038.370	278	RC	C1713	CPT				Both			3273	1472.85	1472.85	2945.7		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	2422.02							Fee Schedule																													2945.7							Fee Schedule																																															
SYNTHES TFNA BLADE 75MM 04.038.375	278	RC	C1713	CPT				Both			3273	1472.85	1472.85	2945.7		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	2422.02							Fee Schedule																													2945.7							Fee Schedule																																															
SYNTHES TFNA BLADE 90MM 04.038.390	278	RC	C1713	CPT				Both			3247	1461.15	1461.15	2922.3		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	2402.78							Fee Schedule																													2922.3							Fee Schedule																																															
SYNTHES TFNA SHORT 170MM # 04.037.042S	278	RC	C1713	CPT				Both			8199	3689.55	3689.55	7379.1		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	6067.26							Fee Schedule																													7379.1							Fee Schedule																																															
SYNTHES TI END CAP # 04.004.002S	278	RC	C1713	CPT				Both			981.75	441.79	441.79	883.58		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	726.5							Fee Schedule																													883.58							Fee Schedule																																															
SYNTHES TI HELICAL BLADE #456.303	272	RC						Both			2668.05	1200.62	1200.62	2401.25	1734.23							Fee Schedule		1974.36							Fee Schedule																													2401.25							Fee Schedule																																															
SYNTHES TI LOCK SCREW # 04.005.526S	278	RC	C1713	CPT				Both			1071	481.95	481.95	963.9		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	792.54							Fee Schedule																													963.9							Fee Schedule																																															
SYNTHES TI LOCK SCREW # 04.005.538S	278	RC	C1713	CPT				Both			810.6	364.77	364.77	729.54		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	599.84							Fee Schedule																													729.54							Fee Schedule																																															
SYNTHES TIB. NAIL END CAP # 04.004.009	278	RC						Both			943.95	424.78	424.78	849.56		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	698.52							Fee Schedule																													849.56							Fee Schedule																																															
SYNTHES TIB. NAIL END CAP # 04.004.010S	278	RC						Both			876.75	394.54	394.54	789.08		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	648.8							Fee Schedule																													789.08							Fee Schedule																																															
SYNTHES TIBIA PLATE 3.5MM 02.127.210	278	RC	C1713	CPT				Both			7965	3584.25	3584.25	7168.5		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	5894.1							Fee Schedule																													7168.5							Fee Schedule																																															
SYNTHES TIBIA PLATE 3.5MM 02.127.211	278	RC	C1713	CPT				Both			7965	3584.25	3584.25	7168.5		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	5894.1							Fee Schedule																													7168.5							Fee Schedule																																															
SYNTHES TIBIAL NAIL # 04.034.446S	278	RC	C1713	CPT				Both			6066.9	2730.11	2730.11	5460.21		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	4489.51							Fee Schedule																													5460.21							Fee Schedule																																															
SYNTHES TIBIAL NAIL 04.034.237S	278	RC	C1713	CPT				Both			5670	2551.5	2551.5	5103		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	4195.8							Fee Schedule																													5103							Fee Schedule																																															
SYNTHES TIBIAL NAIL 04.034.243S	278	RC	C1713	CPT				Both			5503.05	2476.37	2476.37	4952.75		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	4072.26							Fee Schedule																													4952.75							Fee Schedule																																															
SYNTHES TIBIAL NAIL 04.034.452S	278	RC	C1713	CPT				Both			5316.15	2392.27	2392.27	4784.54		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	3933.95							Fee Schedule																													4784.54							Fee Schedule																																															
SYNTHES TIBIAL NAIL 10MM # 04.004.458S	278	RC	C1713	CPT				Both			4987.5	2244.38	2244.38	4488.75		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	3690.75							Fee Schedule																													4488.75							Fee Schedule																																															
SYNTHES TITANIUM SCREW 04.038.070	278	RC	C1713	CPT				Both			2838.15	1277.17	1277.17	2554.34		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	2100.23							Fee Schedule																													2554.34							Fee Schedule																																															
SYNTHES TITANIUM SCREW 04.038.130	278	RC	C1713	CPT				Both			2838.15	1277.17	1277.17	2554.34		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	2100.23							Fee Schedule																													2554.34							Fee Schedule																																															
SYNTHES VA SCREW 5.0 CANN 02.231.625	278	RC	C1713	CPT				Both			1105.65	497.54	497.54	995.09		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	818.18							Fee Schedule																													995.09							Fee Schedule																																															
SYNTHES VA SCREW 5.0 CANN 02.231.660	278	RC	C1713	CPT				Both			1105.65	497.54	497.54	995.09		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	818.18							Fee Schedule																													995.09							Fee Schedule																																															
SYNTHES VA SCREW 5.0 CANN 02.231.665	278	RC	C1713	CPT				Both			1105.65	497.54	497.54	995.09		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	818.18							Fee Schedule																													995.09							Fee Schedule																																															
SYNTHES VA SCREW 5.0 CANN 02.231.670	278	RC	C1713	CPT				Both			1105.65	497.54	497.54	995.09		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	818.18							Fee Schedule																													995.09							Fee Schedule																																															
SYNTHES VA SCREW 5.0 CANN 02.231.675	278	RC	C1713	CPT				Both			1105.65	497.54	497.54	995.09		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	818.18							Fee Schedule																													995.09							Fee Schedule																																															
SYNTHES VA SCREW 5.0 CANN 02.231.680	278	RC	C1713	CPT				Both			1105.65	497.54	497.54	995.09		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	818.18							Fee Schedule																													995.09							Fee Schedule																																															
SYNTHESE  FIXATION NAIL 456.473S	278	RC	C1713	CPT				Both			7941.15	3573.52	3573.52	7147.04		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	5876.45							Fee Schedule																													7147.04							Fee Schedule																																															
SYNTHESE 1.5 SCREW #401.812	278	RC	C1713	CPT				Both			170.1	76.55	76.55	153.09		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	125.87							Fee Schedule																													153.09							Fee Schedule																																															
SYNTHESE 1.5 SCREW #401.814	278	RC	C1713	CPT				Both			170.1	76.55	76.55	153.09		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	125.87							Fee Schedule																													153.09							Fee Schedule																																															
SYNTHESE 1/3 TUBE PLATE 241.401	278	RC	C1713	CPT				Both			890	400.5	400.5	801		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	658.6							Fee Schedule																													801							Fee Schedule																																															
SYNTHESE 1/3 TUBE PLATE 241.421	278	RC	C1713	CPT				Both			785.4	353.43	353.43	706.86		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	581.2							Fee Schedule																													706.86							Fee Schedule																																															
SYNTHESE 1/3 TUBE PLT W/COLLAR 241.40	278	RC	C1713	CPT				Both			136.5	61.43	61.43	122.85		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	101.01							Fee Schedule																													122.85							Fee Schedule																																															
SYNTHESE 1/3 TUBULAR PLATE 2 HOLE 241.32	278	RC	C1713	CPT				Both			103.95	46.78	46.78	93.56		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	76.92							Fee Schedule																													93.56							Fee Schedule																																															
SYNTHESE 1/3 TUBULAR PLATE 3 HOLE 241.33	278	RC	C1713	CPT				Both			109.2	49.14	49.14	98.28		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	80.81							Fee Schedule																													98.28							Fee Schedule																																															
SYNTHESE 1/3 TUBULAR PLATE 4 HOLE 241.34	278	RC	C1713	CPT				Both			127.05	57.17	57.17	114.35		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	94.02							Fee Schedule																													114.35							Fee Schedule																																															
SYNTHESE 1/3 TUBULAR PLATE 5 HOLE 241.35	278	RC	C1713	CPT				Both			127.05	57.17	57.17	114.35		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	94.02							Fee Schedule																													114.35							Fee Schedule																																															
SYNTHESE 1/3 TUBULAR PLATE 6 HOLE 241.36	278	RC	C1713	CPT				Both			130.2	58.59	58.59	117.18		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	96.35							Fee Schedule																													117.18							Fee Schedule																																															
SYNTHESE 1/3 TUBULAR PLATE 7 HOLE 241.37	278	RC	C1713	CPT				Both			538.65	242.39	242.39	484.79		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	398.6							Fee Schedule																													484.79							Fee Schedule																																															
SYNTHESE 1/3 TUBULAR PLATE 8 HOLE 241.38	278	RC	C1713	CPT				Both			136.5	61.43	61.43	122.85		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	101.01							Fee Schedule																													122.85							Fee Schedule																																															
SYNTHESE 1/3 TUBULAR PT 10HOLE 241.20	278	RC	C1713	CPT				Both			136.5	61.43	61.43	122.85		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	101.01							Fee Schedule																													122.85							Fee Schedule																																															
SYNTHESE 10 HOLE PLATE 02.001.300	278	RC	C1713	CPT				Both			5159.7	2321.87	2321.87	4643.73		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	3818.18							Fee Schedule																													4643.73							Fee Schedule																																															
SYNTHESE 10 HOLE PLATE 02.001.320	278	RC	C1713	CPT				Both			5159.7	2321.87	2321.87	4643.73		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	3818.18							Fee Schedule																													4643.73							Fee Schedule																																															
SYNTHESE 115 HELICAL BLADE SCR 456.308	272	RC						Both			2668.05	1200.62	1200.62	2401.25	1734.23							Fee Schedule		1974.36							Fee Schedule																													2401.25							Fee Schedule																																															
SYNTHESE 11MM CARBON FIBER ROD 394.84	278	RC						Both			822.15	369.97	369.97	739.94		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	608.39							Fee Schedule																													739.94							Fee Schedule																																															
SYNTHESE 12 HOLE PLATE 02.001.302	278	RC	C1713	CPT				Both			5267.85	2370.53	2370.53	4741.07		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	3898.21							Fee Schedule																													4741.07							Fee Schedule																																															
SYNTHESE 12 HOLE PLATE 02.001.304	278	RC	C1713	CPT				Both			5376	2419.2	2419.2	4838.4		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	3978.24							Fee Schedule																													4838.4							Fee Schedule																																															
SYNTHESE 12 HOLE PLATE 02.001.322	278	RC	C1713	CPT				Both			5267.85	2370.53	2370.53	4741.07		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	3898.21							Fee Schedule																													4741.07							Fee Schedule																																															
SYNTHESE 12 HOLE PLATE 02.001.324	278	RC	C1713	CPT				Both			5376	2419.2	2419.2	4838.4		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	3978.24							Fee Schedule																													4838.4							Fee Schedule																																															
SYNTHESE 12MM FIXATION NAIL 456.476S	278	RC	C1713	CPT				Both			7941.15	3573.52	3573.52	7147.04		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	5876.45							Fee Schedule																													7147.04							Fee Schedule																																															
SYNTHESE 12MM FIXATION NAIL 456.477S	278	RC	C1713	CPT				Both			6932.1	3119.45	3119.45	6238.89		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	5129.75							Fee Schedule																													6238.89							Fee Schedule																																															
SYNTHESE 135 DEG DHS PLATE 4HOLE 281.140	278	RC	C1713	CPT				Both			2341	1053.45	1053.45	2106.9		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1732.34							Fee Schedule																													2106.9							Fee Schedule																																															
SYNTHESE 2.4 CORTICAL SCREW 201.630	278	RC	C1713	CPT				Both			98.7	44.42	44.42	88.83		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	73.04							Fee Schedule																													88.83							Fee Schedule																																															
SYNTHESE 2.4MM TITANUM 10MM S/T 412.810	278	RC	C1713	CPT				Both			308.7	138.92	138.92	277.83		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	228.44							Fee Schedule																													277.83							Fee Schedule																																															
SYNTHESE 2.4MM TITANUM 12MM S/T 412.812	278	RC	C1713	CPT				Both			308.7	138.92	138.92	277.83		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	228.44							Fee Schedule																													277.83							Fee Schedule																																															
SYNTHESE 2.4MM TITANUM 14MM S/T 412.814	278	RC	C1713	CPT				Both			371.7	167.27	167.27	334.53		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	275.06							Fee Schedule																													334.53							Fee Schedule																																															
SYNTHESE 2.4MM TITANUM 16MM S/T 412.816	278	RC	C1713	CPT				Both			371.7	167.27	167.27	334.53		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	275.06							Fee Schedule																													334.53							Fee Schedule																																															
SYNTHESE 2.4MM TITANUM 24MM S/T 412.824	278	RC	C1713	CPT				Both			371.7	167.27	167.27	334.53		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	275.06							Fee Schedule																													334.53							Fee Schedule																																															
SYNTHESE 2.4MM TITANUM 26MM S/T 412.826	278	RC	C1713	CPT				Both			368.55	165.85	165.85	331.7		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	272.73							Fee Schedule																													331.7							Fee Schedule																																															
SYNTHESE 2.4MM TITANUM 28MM S/T 412.828	278	RC	C1713	CPT				Both			368.55	165.85	165.85	331.7		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	272.73							Fee Schedule																													331.7							Fee Schedule																																															
SYNTHESE 2.4MM TITANUM 30MM S/T 412.830	278	RC	C1713	CPT				Both			308.7	138.92	138.92	277.83		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	228.44							Fee Schedule																													277.83							Fee Schedule																																															
SYNTHESE 2.4MM TITANUM 6MM S/T 412.806	278	RC	C1713	CPT				Both			308.7	138.92	138.92	277.83		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	228.44							Fee Schedule																													277.83							Fee Schedule																																															
SYNTHESE 2.4MM TITANUM 8MM S/T 412.808	278	RC	C1713	CPT				Both			308.7	138.92	138.92	277.83		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	228.44							Fee Schedule																													277.83							Fee Schedule																																															
SYNTHESE 2.7 CORTICAL SCREW 202.810	278	RC	C1713	CPT				Both			201	90.45	90.45	180.9		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	148.74							Fee Schedule																													180.9							Fee Schedule																																															
SYNTHESE 2.7 CORTICAL SCREW 202.812	278	RC	C1713	CPT				Both			201	90.45	90.45	180.9		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	148.74							Fee Schedule																													180.9							Fee Schedule																																															
SYNTHESE 2.7 CORTICAL SCREW 202.814	278	RC	C1713	CPT				Both			201	90.45	90.45	180.9		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	148.74							Fee Schedule																													180.9							Fee Schedule																																															
SYNTHESE 2.7 CORTICAL SCREW 202.816	278	RC	C1713	CPT				Both			230	103.5	103.5	207		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	170.2							Fee Schedule																													207							Fee Schedule																																															
SYNTHESE 2.7 CORTICAL SCREW 202.818	278	RC	C1713	CPT				Both			201	90.45	90.45	180.9		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	148.74							Fee Schedule																													180.9							Fee Schedule																																															
SYNTHESE 2.7 CORTICAL SCREW 202.820	278	RC	C1713	CPT				Both			201	90.45	90.45	180.9		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	148.74							Fee Schedule																													180.9							Fee Schedule																																															
SYNTHESE 2.7 CORTICAL SCREW 202.826	278	RC	C1713	CPT				Both			201	90.45	90.45	180.9		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	148.74							Fee Schedule																													180.9							Fee Schedule																																															
SYNTHESE 212.820	278	RC	C1713	CPT				Both			363.3	163.49	163.49	326.97		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	268.84							Fee Schedule																													326.97							Fee Schedule																																															
SYNTHESE 212.822	278	RC	C1713	CPT				Both			363.3	163.49	163.49	326.97		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	268.84							Fee Schedule																													326.97							Fee Schedule																																															
SYNTHESE 3 HOLE LCP PLATE 241.931	278	RC	C1713	CPT				Both			782.25	352.01	352.01	704.03		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	578.87							Fee Schedule																													704.03							Fee Schedule																																															
SYNTHESE 3 HOLE PLATE # 02.123.040	278	RC	C1713	CPT				Both			5845.35	2630.41	2630.41	5260.82		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	4325.56							Fee Schedule																													5260.82							Fee Schedule																																															
SYNTHESE 3.2 DRILL BIT #310.31	270	RC						Both			316	142.2	142.2	284.4	205.4							Fee Schedule		233.84							Fee Schedule																													284.4							Fee Schedule																																															
SYNTHESE 3.5 14MM LOCKED SCREW 212.104	278	RC	C1713	CPT				Both			567	255.15	255.15	510.3		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	419.58							Fee Schedule																													510.3							Fee Schedule																																															
SYNTHESE 3.5 14MM LOCKED SCREW 212.105	278	RC	C1713	CPT				Both			630	283.5	283.5	567		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	466.2							Fee Schedule																													567							Fee Schedule																																															
SYNTHESE 3.5 CORTEX SCREW 204.848	278	RC	C1713	CPT				Both			180	81	81	162		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	133.2							Fee Schedule																													162							Fee Schedule																																															
SYNTHESE 3.5 CORTEX SCREW S/T 204.810	278	RC	C1713	CPT				Both			141.75	63.79	63.79	127.58		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	104.9							Fee Schedule																													127.58							Fee Schedule																																															
SYNTHESE 3.5 CORTEX SCREW S/T 204.812	278	RC	C1713	CPT				Both			144	64.8	64.8	129.6		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	106.56							Fee Schedule																													129.6							Fee Schedule																																															
SYNTHESE 3.5 CORTEX SCREW S/T 204.814	278	RC	C1713	CPT				Both			144	64.8	64.8	129.6		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	106.56							Fee Schedule																													129.6							Fee Schedule																																															
SYNTHESE 3.5 CORTEX SCREW S/T 204.816	278	RC	C1713	CPT				Both			144	64.8	64.8	129.6		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	106.56							Fee Schedule																													129.6							Fee Schedule																																															
SYNTHESE 3.5 CORTEX SCREW S/T 204.820	278	RC	C1713	CPT				Both			144	64.8	64.8	129.6		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	106.56							Fee Schedule																													129.6							Fee Schedule																																															
SYNTHESE 3.5 CORTEX SCREW S/T 204.824	278	RC	C1713	CPT				Both			102.9	46.31	46.31	92.61		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	76.15							Fee Schedule																													92.61							Fee Schedule																																															
SYNTHESE 3.5 CORTEX SCREW S/T 204.826	278	RC	C1713	CPT				Both			117	52.65	52.65	105.3		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	86.58							Fee Schedule																													105.3							Fee Schedule																																															
SYNTHESE 3.5 CORTEX SCREW S/T 204.828	278	RC	C1713	CPT				Both			117	52.65	52.65	105.3		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	86.58							Fee Schedule																													105.3							Fee Schedule																																															
SYNTHESE 3.5 CORTEX SCREW S/T 204.830	278	RC	C1713	CPT				Both			117	52.65	52.65	105.3		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	86.58							Fee Schedule																													105.3							Fee Schedule																																															
SYNTHESE 3.5 CORTEX SCREW S/T 204.832	278	RC	C1713	CPT				Both			117	52.65	52.65	105.3		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	86.58							Fee Schedule																													105.3							Fee Schedule																																															
SYNTHESE 3.5 CORTEX SCREW S/T 204.834	278	RC	C1713	CPT				Both			117	52.65	52.65	105.3		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	86.58							Fee Schedule																													105.3							Fee Schedule																																															
SYNTHESE 3.5 CORTEX SCREW S/T 204.836	278	RC	C1713	CPT				Both			117	52.65	52.65	105.3		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	86.58							Fee Schedule																													105.3							Fee Schedule																																															
SYNTHESE 3.5 CORTEX SCREW S/T 204.838	278	RC	C1713	CPT				Both			117	52.65	52.65	105.3		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	86.58							Fee Schedule																													105.3							Fee Schedule																																															
SYNTHESE 3.5 CORTEX SCREW S/T 204.840	278	RC	C1713	CPT				Both			117	52.65	52.65	105.3		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	86.58							Fee Schedule																													105.3							Fee Schedule																																															
SYNTHESE 3.5 CORTEX SCREW S/T 204.844	278	RC	C1713	CPT				Both			180	81	81	162		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	133.2							Fee Schedule																													162							Fee Schedule																																															
SYNTHESE 3.5 CORTEX SCREW S/T 204.850	278	RC	C1713	CPT				Both			180	81	81	162		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	133.2							Fee Schedule																													162							Fee Schedule																																															
SYNTHESE 3.5 CORTEX SCREW S/T 204.855	278	RC	C1713	CPT				Both			172	77.4	77.4	154.8		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	127.28							Fee Schedule																													154.8							Fee Schedule																																															
SYNTHESE 3.5 CORTEX SCREW S/T 204.860	278	RC	C1713	CPT				Both			180	81	81	162		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	133.2							Fee Schedule																													162							Fee Schedule																																															
SYNTHESE 3.5 CORTEX SCREW S/T 204.865	278	RC	C1713	CPT				Both			46.2	20.79	20.79	41.58		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	34.19							Fee Schedule																													41.58							Fee Schedule																																															
SYNTHESE 3.5 CORTEX SCREW S/T 204.870	278	RC	C1713	CPT				Both			46.2	20.79	20.79	41.58		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	34.19							Fee Schedule																													41.58							Fee Schedule																																															
SYNTHESE 3.5 CORTEX SCREW S/T 204.880	278	RC	C1713	CPT				Both			46.2	20.79	20.79	41.58		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	34.19							Fee Schedule																													41.58							Fee Schedule																																															
SYNTHESE 3.5 CORTEX SCREW S/T 204.885	278	RC	C1713	CPT				Both			46.2	20.79	20.79	41.58		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	34.19							Fee Schedule																													41.58							Fee Schedule																																															
SYNTHESE 3.5 CORTEX SCREW S/T 204.890	278	RC	C1713	CPT				Both			46.2	20.79	20.79	41.58		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	34.19							Fee Schedule																													41.58							Fee Schedule																																															
SYNTHESE 3.5 CORTEX SCREW S/T 204.895	278	RC	C1713	CPT				Both			46.2	20.79	20.79	41.58		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	34.19							Fee Schedule																													41.58							Fee Schedule																																															
SYNTHESE 3.5 CORTEX SCREW S/T 204.900	278	RC	C1713	CPT				Both			46.2	20.79	20.79	41.58		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	34.19							Fee Schedule																													41.58							Fee Schedule																																															
SYNTHESE 3.5 CORTEX SCREW S/T 204.905	278	RC	C1713	CPT				Both			46.2	20.79	20.79	41.58		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	34.19							Fee Schedule																													41.58							Fee Schedule																																															
SYNTHESE 3.5 CORTEX SCREW S/T 204.910	278	RC	C1713	CPT				Both			46.2	20.79	20.79	41.58		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	34.19							Fee Schedule																													41.58							Fee Schedule																																															
SYNTHESE 3.5 LOCK SCREW 212.102	278	RC	C1713	CPT				Both			642	288.9	288.9	577.8		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	475.08							Fee Schedule																													577.8							Fee Schedule																																															
SYNTHESE 3.5 LOCK TAP SCREW #212.110	278	RC	C1713	CPT				Both			456.75	205.54	205.54	411.08		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	338							Fee Schedule																													411.08							Fee Schedule																																															
SYNTHESE 3.5 LOCK TAP SCREW #212.112	278	RC	C1713	CPT				Both			567	255.15	255.15	510.3		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	419.58							Fee Schedule																													510.3							Fee Schedule																																															
SYNTHESE 3.5 LOCKING SCREW #212.119	278	RC	C1713	CPT				Both			490.35	220.66	220.66	441.32		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	362.86							Fee Schedule																													441.32							Fee Schedule																																															
SYNTHESE 3.5 LOCKING SCREW #212.121	278	RC	C1713	CPT				Both			642	288.9	288.9	577.8		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	475.08							Fee Schedule																													577.8							Fee Schedule																																															
SYNTHESE 3.5 LOCKING SCREW 20MM 212.106	278	RC	C1713	CPT				Both			301.35	135.61	135.61	271.22		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	223							Fee Schedule																													271.22							Fee Schedule																																															
SYNTHESE 3.5 LOCKING SCREW 22MM 212.107	278	RC	C1713	CPT				Both			261.45	117.65	117.65	235.31		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	193.47							Fee Schedule																													235.31							Fee Schedule																																															
SYNTHESE 3.5 RECON PLATE 245.071	278	RC	C1713	CPT				Both			2661	1197.45	1197.45	2394.9		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1969.14							Fee Schedule																													2394.9							Fee Schedule																																															
SYNTHESE 3.5 RECON PLATE 245.081	278	RC	C1713	CPT				Both			1270.5	571.73	571.73	1143.45		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	940.17							Fee Schedule																													1143.45							Fee Schedule																																															
SYNTHESE 3.5 RECONSTRCT PLATE 245.00	278	RC	C1713	CPT				Both			953.4	429.03	429.03	858.06		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	705.52							Fee Schedule																													858.06							Fee Schedule																																															
SYNTHESE 3.5 RECONSTRCT PLATE 245.19	278	RC	C1713	CPT				Both			941.85	423.83	423.83	847.67		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	696.97							Fee Schedule																													847.67							Fee Schedule																																															
SYNTHESE 3.5 SCREW 223.621	278	RC	C1713	CPT				Both			1471.05	661.97	661.97	1323.95		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1088.58							Fee Schedule																													1323.95							Fee Schedule																																															
SYNTHESE 3.5MM LC-DCP PLATE 223.56	278	RC	C1713	CPT				Both			281.4	126.63	126.63	253.26		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	208.24							Fee Schedule																													253.26							Fee Schedule																																															
SYNTHESE 3.5MM LC-DCP PLATE 223.57	278	RC	C1713	CPT				Both			292.95	131.83	131.83	263.66		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	216.78							Fee Schedule																													263.66							Fee Schedule																																															
SYNTHESE 3.5MM LC-DCP PLATE 223.58	278	RC	C1713	CPT				Both			308.7	138.92	138.92	277.83		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	228.44							Fee Schedule																													277.83							Fee Schedule																																															
SYNTHESE 3.5MM LC-DCP PLATE 223.59	278	RC	C1713	CPT				Both			320.25	144.11	144.11	288.23		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	236.99							Fee Schedule																													288.23							Fee Schedule																																															
SYNTHESE 3.5MM LC-DCP PLATE 223.60	278	RC	C1713	CPT				Both			328.65	147.89	147.89	295.79		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	243.2							Fee Schedule																													295.79							Fee Schedule																																															
SYNTHESE 3.5MM RECONSTRUCT PLATE 245.15	278	RC	C1713	CPT				Both			726.6	326.97	326.97	653.94		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	537.68							Fee Schedule																													653.94							Fee Schedule																																															
SYNTHESE 3.5MM RECONSTRUCT PLATE 245.16	278	RC	C1713	CPT				Both			842.1	378.95	378.95	757.89		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	623.15							Fee Schedule																													757.89							Fee Schedule																																															
SYNTHESE 3.5MM RECONSTRUCT PLATE 245.17	278	RC	C1713	CPT				Both			887.25	399.26	399.26	798.53		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	656.57							Fee Schedule																													798.53							Fee Schedule																																															
SYNTHESE 3.5MM RECONSTRUCT PLATE 245.18	278	RC	C1713	CPT				Both			920.85	414.38	414.38	828.77		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	681.43							Fee Schedule																													828.77							Fee Schedule																																															
SYNTHESE 3.9 BOLT FOR IM NAIL  458.40	278	RC	C1713	CPT				Both			374.85	168.68	168.68	337.37		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	277.39							Fee Schedule																													337.37							Fee Schedule																																															
SYNTHESE 4 HOLE PLATE #240.037	278	RC	C1713	CPT				Both			4637.85	2087.03	2087.03	4174.07		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	3432.01							Fee Schedule																													4174.07							Fee Schedule																																															
SYNTHESE 4.0 BOLT #458.828	278	RC	C1713	CPT				Both			425.25	191.36	191.36	382.73		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	314.69							Fee Schedule																													382.73							Fee Schedule																																															
SYNTHESE 4.0 BOLT #458.842	278	RC	C1713	CPT				Both			396.9	178.61	178.61	357.21		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	293.71							Fee Schedule																													357.21							Fee Schedule																																															
SYNTHESE 4.0 CANCEL. SCREW PT 207.010	278	RC	C1713	CPT				Both			201	90.45	90.45	180.9		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	148.74							Fee Schedule																													180.9							Fee Schedule																																															
SYNTHESE 4.0 CANCEL. SCREW PT 207.012	278	RC	C1713	CPT				Both			201	90.45	90.45	180.9		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	148.74							Fee Schedule																													180.9							Fee Schedule																																															
SYNTHESE 4.0 CANCEL. SCREW PT 207.014	278	RC	C1713	CPT				Both			80.85	36.38	36.38	72.77		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	59.83							Fee Schedule																													72.77							Fee Schedule																																															
SYNTHESE 4.0 CANCEL. SCREW PT 207.016	278	RC	C1713	CPT				Both			201	90.45	90.45	180.9		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	148.74							Fee Schedule																													180.9							Fee Schedule																																															
SYNTHESE 4.0 CANCEL. SCREW PT 207.018	278	RC	C1713	CPT				Both			201	90.45	90.45	180.9		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	148.74							Fee Schedule																													180.9							Fee Schedule																																															
SYNTHESE 4.0 CANCEL. SCREW PT 207.020	278	RC	C1713	CPT				Both			201	90.45	90.45	180.9		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	148.74							Fee Schedule																													180.9							Fee Schedule																																															
SYNTHESE 4.0 CANCEL. SCREW PT 207.022	278	RC	C1713	CPT				Both			201	90.45	90.45	180.9		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	148.74							Fee Schedule																													180.9							Fee Schedule																																															
SYNTHESE 4.0 CANCEL. SCREW PT 207.024	278	RC	C1713	CPT				Both			201	90.45	90.45	180.9		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	148.74							Fee Schedule																													180.9							Fee Schedule																																															
SYNTHESE 4.0 CANCEL. SCREW PT 207.026	278	RC	C1713	CPT				Both			92.4	41.58	41.58	83.16		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	68.38							Fee Schedule																													83.16							Fee Schedule																																															
SYNTHESE 4.0 CANCEL. SCREW PT 207.028	278	RC	C1713	CPT				Both			68.25	30.71	30.71	61.43		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	50.51							Fee Schedule																													61.43							Fee Schedule																																															
SYNTHESE 4.0 CANCEL. SCREW PT 207.030	278	RC	C1713	CPT				Both			80.85	36.38	36.38	72.77		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	59.83							Fee Schedule																													72.77							Fee Schedule																																															
SYNTHESE 4.0 CANCEL. SCREW PT 207.035	278	RC	C1713	CPT				Both			90	40.5	40.5	81		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	66.6							Fee Schedule																													81							Fee Schedule																																															
SYNTHESE 4.0 CANCEL. SCREW PT 207.040	278	RC	C1713	CPT				Both			90	40.5	40.5	81		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	66.6							Fee Schedule																													81							Fee Schedule																																															
SYNTHESE 4.0 CANCEL. SCREW PT 207.045	278	RC	C1713	CPT				Both			66.15	29.77	29.77	59.54		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	48.95							Fee Schedule																													59.54							Fee Schedule																																															
SYNTHESE 4.0 CANCEL. SCREW PT 207.050	278	RC	C1713	CPT				Both			201	90.45	90.45	180.9		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	148.74							Fee Schedule																													180.9							Fee Schedule																																															
SYNTHESE 4.0 CANN SCREW 10MM 206.010	278	RC	C1713	CPT				Both			201	90.45	90.45	180.9		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	148.74							Fee Schedule																													180.9							Fee Schedule																																															
SYNTHESE 4.0 CANN SCREW 12MM 206.012	278	RC	C1713	CPT				Both			96	43.2	43.2	86.4		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	71.04							Fee Schedule																													86.4							Fee Schedule																																															
SYNTHESE 4.0 CANN SCREW 14MM 206.014	278	RC	C1713	CPT				Both			211	94.95	94.95	189.9		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	156.14							Fee Schedule																													189.9							Fee Schedule																																															
SYNTHESE 4.0 CANN SCREW 16MM 206.016	278	RC	C1713	CPT				Both			211	94.95	94.95	189.9		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	156.14							Fee Schedule																													189.9							Fee Schedule																																															
SYNTHESE 4.0 CANN SCREW 18MM 206.018	278	RC	C1713	CPT				Both			211	94.95	94.95	189.9		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	156.14							Fee Schedule																													189.9							Fee Schedule																																															
SYNTHESE 4.0 CANN SCREW 20MM 206.020	278	RC	C1713	CPT				Both			211	94.95	94.95	189.9		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	156.14							Fee Schedule																													189.9							Fee Schedule																																															
SYNTHESE 4.0 CANN SCREW 22MM 206.022	278	RC	C1713	CPT				Both			211	94.95	94.95	189.9		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	156.14							Fee Schedule																													189.9							Fee Schedule																																															
SYNTHESE 4.0 CANN SCREW 24MM 206.024	278	RC	C1713	CPT				Both			96	43.2	43.2	86.4		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	71.04							Fee Schedule																													86.4							Fee Schedule																																															
SYNTHESE 4.0 CANN SCREW 26MM 206.026	278	RC	C1713	CPT				Both			211	94.95	94.95	189.9		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	156.14							Fee Schedule																													189.9							Fee Schedule																																															
SYNTHESE 4.0 CANN SCREW 28MM 206.028	278	RC	C1713	CPT				Both			88	39.6	39.6	79.2		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	65.12							Fee Schedule																													79.2							Fee Schedule																																															
SYNTHESE 4.0 CANN SCREW 30MM 206.030	278	RC	C1713	CPT				Both			233.1	104.9	104.9	209.79		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	172.49							Fee Schedule																													209.79							Fee Schedule																																															
SYNTHESE 4.0 CANN SCREW 35MM 206.035	278	RC	C1713	CPT				Both			96	43.2	43.2	86.4		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	71.04							Fee Schedule																													86.4							Fee Schedule																																															
SYNTHESE 4.0 CANN SCREW 40MM 206.040	278	RC	C1713	CPT				Both			96	43.2	43.2	86.4		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	71.04							Fee Schedule																													86.4							Fee Schedule																																															
SYNTHESE 4.0 CANN SCREW 45MM 206.045	278	RC	C1713	CPT				Both			79	35.55	35.55	71.1		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	58.46							Fee Schedule																													71.1							Fee Schedule																																															
SYNTHESE 4.0 CANN SCREW 50MM 206.050	278	RC	C1713	CPT				Both			201	90.45	90.45	180.9		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	148.74							Fee Schedule																													180.9							Fee Schedule																																															
SYNTHESE 4.0 CANN SCREW 55MM 206.055	278	RC	C1713	CPT				Both			96	43.2	43.2	86.4		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	71.04							Fee Schedule																													86.4							Fee Schedule																																															
SYNTHESE 4.0 CANN SCREW 60MM 206.060	278	RC	C1713	CPT				Both			86.1	38.75	38.75	77.49		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	63.71							Fee Schedule																													77.49							Fee Schedule																																															
SYNTHESE 4.0 CANN SCREW RACK SET 304.313	278	RC	C1713	CPT				Both			694.05	312.32	312.32	624.65		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	513.6							Fee Schedule																													624.65							Fee Schedule																																															
SYNTHESE 4.0 CANN SCREW SHT THRD 207.610	278	RC	C1713	CPT				Both			927.15	417.22	417.22	834.44		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	686.09							Fee Schedule																													834.44							Fee Schedule																																															
SYNTHESE 4.0 CANN SCREW SHT THRD 207.612	278	RC	C1713	CPT				Both			429.45	193.25	193.25	386.51		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	317.79							Fee Schedule																													386.51							Fee Schedule																																															
SYNTHESE 4.0 CANN SCREW SHT THRD 207.614	278	RC	C1713	CPT				Both			429.45	193.25	193.25	386.51		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	317.79							Fee Schedule																													386.51							Fee Schedule																																															
SYNTHESE 4.0 CANN SCREW SHT THRD 207.616	278	RC	C1713	CPT				Both			429.45	193.25	193.25	386.51		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	317.79							Fee Schedule																													386.51							Fee Schedule																																															
SYNTHESE 4.0 CANN SCREW SHT THRD 207.618	278	RC	C1713	CPT				Both			429.45	193.25	193.25	386.51		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	317.79							Fee Schedule																													386.51							Fee Schedule																																															
SYNTHESE 4.0 CANN SCREW SHT THRD 207.620	278	RC	C1713	CPT				Both			780	351	351	702		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	577.2							Fee Schedule																													702							Fee Schedule																																															
SYNTHESE 4.0 CANN SCREW SHT THRD 207.622	278	RC	C1713	CPT				Both			683.55	307.6	307.6	615.2		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	505.83							Fee Schedule																													615.2							Fee Schedule																																															
SYNTHESE 4.0 CANN SCREW SHT THRD 207.624	278	RC	C1713	CPT				Both			780	351	351	702		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	577.2							Fee Schedule																													702							Fee Schedule																																															
SYNTHESE 4.0 CANN SCREW SHT THRD 207.626	278	RC	C1713	CPT				Both			927.15	417.22	417.22	834.44		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	686.09							Fee Schedule																													834.44							Fee Schedule																																															
SYNTHESE 4.0 CANN SCREW SHT THRD 207.628	278	RC	C1713	CPT				Both			780	351	351	702		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	577.2							Fee Schedule																													702							Fee Schedule																																															
SYNTHESE 4.0 CANN SCREW SHT THRD 207.630	278	RC	C1713	CPT				Both			780	351	351	702		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	577.2							Fee Schedule																													702							Fee Schedule																																															
SYNTHESE 4.0 CANN SCREW SHT THRD 207.632	278	RC	C1713	CPT				Both			1011	454.95	454.95	909.9		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	748.14							Fee Schedule																													909.9							Fee Schedule																																															
SYNTHESE 4.0 CANN SCREW SHT THRD 207.634	278	RC	C1713	CPT				Both			780	351	351	702		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	577.2							Fee Schedule																													702							Fee Schedule																																															
SYNTHESE 4.0 CANN SCREW SHT THRD 207.636	278	RC	C1713	CPT				Both			780	351	351	702		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	577.2							Fee Schedule																													702							Fee Schedule																																															
SYNTHESE 4.0 CANN SCREW SHT THRD 207.638	278	RC	C1713	CPT				Both			780	351	351	702		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	577.2							Fee Schedule																													702							Fee Schedule																																															
SYNTHESE 4.0 CANN SCREW SHT THRD 207.640	278	RC	C1713	CPT				Both			819	368.55	368.55	737.1		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	606.06							Fee Schedule																													737.1							Fee Schedule																																															
SYNTHESE 4.0 CANN SCREW SHT THRD 207.642	278	RC	C1713	CPT				Both			819	368.55	368.55	737.1		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	606.06							Fee Schedule																													737.1							Fee Schedule																																															
SYNTHESE 4.0 CANN SCREW SHT THRD 207.644	278	RC	C1713	CPT				Both			866.25	389.81	389.81	779.63		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	641.03							Fee Schedule																													779.63							Fee Schedule																																															
SYNTHESE 4.0 CANN SCREW SHT THRD 207.646	278	RC	C1713	CPT				Both			782.25	352.01	352.01	704.03		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	578.87							Fee Schedule																													704.03							Fee Schedule																																															
SYNTHESE 4.0 CANN SCREW SHT THRD 207.648	278	RC	C1713	CPT				Both			1030.05	463.52	463.52	927.05		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	762.24							Fee Schedule																													927.05							Fee Schedule																																															
SYNTHESE 4.0 CANN SCREW SHT THRD 207.650	278	RC	C1713	CPT				Both			780	351	351	702		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	577.2							Fee Schedule																													702							Fee Schedule																																															
SYNTHESE 4.0 CANNULATED SCREWS 207.716	278	RC	C1713	CPT				Both			462	207.9	207.9	415.8		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	341.88							Fee Schedule																													415.8							Fee Schedule																																															
SYNTHESE 4.0 CANNULATED SCREWS 207.718	278	RC	C1713	CPT				Both			462	207.9	207.9	415.8		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	341.88							Fee Schedule																													415.8							Fee Schedule																																															
SYNTHESE 4.0 CANNULATED SCREWS 207.720	278	RC	C1713	CPT				Both			462	207.9	207.9	415.8		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	341.88							Fee Schedule																													415.8							Fee Schedule																																															
SYNTHESE 4.0 CANNULATED SCREWS 207.722	278	RC	C1713	CPT				Both			462	207.9	207.9	415.8		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	341.88							Fee Schedule																													415.8							Fee Schedule																																															
SYNTHESE 4.0 CANNULATED SCREWS 207.724	278	RC	C1713	CPT				Both			462	207.9	207.9	415.8		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	341.88							Fee Schedule																													415.8							Fee Schedule																																															
SYNTHESE 4.0 CANNULATED SCREWS 207.726	278	RC	C1713	CPT				Both			462	207.9	207.9	415.8		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	341.88							Fee Schedule																													415.8							Fee Schedule																																															
SYNTHESE 4.0 CANNULATED SCREWS 207.728	278	RC	C1713	CPT				Both			462	207.9	207.9	415.8		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	341.88							Fee Schedule																													415.8							Fee Schedule																																															
SYNTHESE 4.0 CANNULATED SCREWS 207.730	278	RC	C1713	CPT				Both			462	207.9	207.9	415.8		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	341.88							Fee Schedule																													415.8							Fee Schedule																																															
SYNTHESE 4.0 CANNULATED SCREWS 207.732	278	RC	C1713	CPT				Both			462	207.9	207.9	415.8		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	341.88							Fee Schedule																													415.8							Fee Schedule																																															
SYNTHESE 4.0 CANNULATED SCREWS 207.734	278	RC	C1713	CPT				Both			462	207.9	207.9	415.8		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	341.88							Fee Schedule																													415.8							Fee Schedule																																															
SYNTHESE 4.0 CANNULATED SCREWS 207.736	278	RC	C1713	CPT				Both			462	207.9	207.9	415.8		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	341.88							Fee Schedule																													415.8							Fee Schedule																																															
SYNTHESE 4.0 CANNULATED SCREWS 207.738	278	RC	C1713	CPT				Both			462	207.9	207.9	415.8		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	341.88							Fee Schedule																													415.8							Fee Schedule																																															
SYNTHESE 4.0 CANNULATED SCREWS 207.740	278	RC	C1713	CPT				Both			462	207.9	207.9	415.8		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	341.88							Fee Schedule																													415.8							Fee Schedule																																															
SYNTHESE 4.0 CANNULATED SCREWS 207.742	278	RC	C1713	CPT				Both			462	207.9	207.9	415.8		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	341.88							Fee Schedule																													415.8							Fee Schedule																																															
SYNTHESE 4.0 CANNULATED SCREWS 207.744	278	RC	C1713	CPT				Both			462	207.9	207.9	415.8		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	341.88							Fee Schedule																													415.8							Fee Schedule																																															
SYNTHESE 4.0 CANNULATED SCREWS 207.746	278	RC	C1713	CPT				Both			462	207.9	207.9	415.8		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	341.88							Fee Schedule																													415.8							Fee Schedule																																															
SYNTHESE 4.0 CANNULATED SCREWS 207.748	278	RC	C1713	CPT				Both			462	207.9	207.9	415.8		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	341.88							Fee Schedule																													415.8							Fee Schedule																																															
SYNTHESE 4.0 CANNULATED SCREWS 207.750	278	RC	C1713	CPT				Both			462	207.9	207.9	415.8		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	341.88							Fee Schedule																													415.8							Fee Schedule																																															
SYNTHESE 4.0 SCREW 222.588	278	RC	C1713	CPT				Both			378	170.1	170.1	340.2		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	279.72							Fee Schedule																													340.2							Fee Schedule																																															
SYNTHESE 4.0MM CANCELLOUS 206.014	278	RC	C1713	CPT				Both			70.35	31.66	31.66	63.32		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	52.06							Fee Schedule																													63.32							Fee Schedule																																															
SYNTHESE 4.0MM CANCELLOUS BONE 206.016	278	RC	C1713	CPT				Both			92.4	41.58	41.58	83.16		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	68.38							Fee Schedule																													83.16							Fee Schedule																																															
SYNTHESE 4.3 DRILL BIT  #310.431	272	RC						Both			567	255.15	255.15	510.3	368.55							Fee Schedule		419.58							Fee Schedule																													510.3							Fee Schedule																																															
SYNTHESE 4.5 CORTEX SCREW 20MM 214.820	278	RC	C1713	CPT				Both			229.95	103.48	103.48	206.96		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	170.16							Fee Schedule																													206.96							Fee Schedule																																															
SYNTHESE 4.5 CORTEX SCREW 214.856	278	RC	C1713	CPT				Both			77.7	34.97	34.97	69.93		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	57.5							Fee Schedule																													69.93							Fee Schedule																																															
SYNTHESE 4.5 CORTEX SCREW 214.860	278	RC	C1713	CPT				Both			51.45	23.15	23.15	46.31		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	38.07							Fee Schedule																													46.31							Fee Schedule																																															
SYNTHESE 4.5 CORTEX SCREW 28MM 214.828	278	RC	C1713	CPT				Both			75.6	34.02	34.02	68.04		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	55.94							Fee Schedule																													68.04							Fee Schedule																																															
SYNTHESE 4.5 CORTEX SCREW 30MM 214.824	278	RC	C1713	CPT				Both			108.15	48.67	48.67	97.34		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	80.03							Fee Schedule																													97.34							Fee Schedule																																															
SYNTHESE 4.5 CORTEX SCREW 30MM 214.826	278	RC	C1713	CPT				Both			79.8	35.91	35.91	71.82		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	59.05							Fee Schedule																													71.82							Fee Schedule																																															
SYNTHESE 4.5 CORTEX SCREW 30MM 214.830	278	RC	C1713	CPT				Both			94.5	42.53	42.53	85.05		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	69.93							Fee Schedule																													85.05							Fee Schedule																																															
SYNTHESE 4.5 CORTEX SCREW 32MM 214.832	278	RC	C1713	CPT				Both			103	46.35	46.35	92.7		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	76.22							Fee Schedule																													92.7							Fee Schedule																																															
SYNTHESE 4.5 CORTEX SCREW 34MM 214.834	278	RC	C1713	CPT				Both			108.15	48.67	48.67	97.34		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	80.03							Fee Schedule																													97.34							Fee Schedule																																															
SYNTHESE 4.5 CORTEX SCREW 36MM  214.836	278	RC	C1713	CPT				Both			108.15	48.67	48.67	97.34		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	80.03							Fee Schedule																													97.34							Fee Schedule																																															
SYNTHESE 4.5 CORTEX SCREW 38MM 214.838	278	RC	C1713	CPT				Both			229.95	103.48	103.48	206.96		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	170.16							Fee Schedule																													206.96							Fee Schedule																																															
SYNTHESE 4.5 CORTEX SCREW 40MM 214.840	278	RC	C1713	CPT				Both			94.5	42.53	42.53	85.05		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	69.93							Fee Schedule																													85.05							Fee Schedule																																															
SYNTHESE 4.5 CORTEX SCREW 42MM 214.842	278	RC	C1713	CPT				Both			94.5	42.53	42.53	85.05		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	69.93							Fee Schedule																													85.05							Fee Schedule																																															
SYNTHESE 4.5 CORTEX SCREW 44MM 214.844	278	RC	C1713	CPT				Both			119.7	53.87	53.87	107.73		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	88.58							Fee Schedule																													107.73							Fee Schedule																																															
SYNTHESE 4.5 CORTEX SCREW 46MM 214.846	278	RC	C1713	CPT				Both			79.8	35.91	35.91	71.82		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	59.05							Fee Schedule																													71.82							Fee Schedule																																															
SYNTHESE 4.5 CORTEX SCREW 48MM 214.848	278	RC	C1713	CPT				Both			108.15	48.67	48.67	97.34		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	80.03							Fee Schedule																													97.34							Fee Schedule																																															
SYNTHESE 4.5 CORTEX SCREW 50MM 214.850	278	RC	C1713	CPT				Both			77.7	34.97	34.97	69.93		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	57.5							Fee Schedule																													69.93							Fee Schedule																																															
SYNTHESE 4.5 CORTEX SCREW 52MM 214.852	278	RC	C1713	CPT				Both			77.7	34.97	34.97	69.93		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	57.5							Fee Schedule																													69.93							Fee Schedule																																															
SYNTHESE 4.5 CORTEX SCREW 54MM 214.854	278	RC	C1713	CPT				Both			75.6	34.02	34.02	68.04		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	55.94							Fee Schedule																													68.04							Fee Schedule																																															
SYNTHESE 4.5 PLATE 222.659	278	RC	C1713	CPT				Both			5733	2579.85	2579.85	5159.7		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	4242.42							Fee Schedule																													5159.7							Fee Schedule																																															
SYNTHESE 5.0 LOCK SCREW 458.932	278	RC	C1713	CPT				Both			453.6	204.12	204.12	408.24		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	335.66							Fee Schedule																													408.24							Fee Schedule																																															
SYNTHESE 5.0 LOCK SCREW 458.936	278	RC	C1713	CPT				Both			808.5	363.83	363.83	727.65		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	598.29							Fee Schedule																													727.65							Fee Schedule																																															
SYNTHESE 5.0 LOCK SCREW 458.940	278	RC	C1713	CPT				Both			703.5	316.58	316.58	633.15		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	520.59							Fee Schedule																													633.15							Fee Schedule																																															
SYNTHESE 5.0 LOCK SCREW 458.944	278	RC	C1713	CPT				Both			808.5	363.83	363.83	727.65		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	598.29							Fee Schedule																													727.65							Fee Schedule																																															
SYNTHESE 5.0 LOCK SCREW 458.946	278	RC	C1713	CPT				Both			703.5	316.58	316.58	633.15		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	520.59							Fee Schedule																													633.15							Fee Schedule																																															
SYNTHESE 5.0 LOCK SCREW 458.950	278	RC	C1713	CPT				Both			808.5	363.83	363.83	727.65		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	598.29							Fee Schedule																													727.65							Fee Schedule																																															
SYNTHESE 5.0 LOCKING SCREW 212.225	278	RC	C1713	CPT				Both			327.6	147.42	147.42	294.84		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	242.42							Fee Schedule																													294.84							Fee Schedule																																															
SYNTHESE 5.0 LOCKING SCREW 212.226	278	RC	C1713	CPT				Both			327.6	147.42	147.42	294.84		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	242.42							Fee Schedule																													294.84							Fee Schedule																																															
SYNTHESE 5.0 LOCKING SCREW 212.227	278	RC	C1713	CPT				Both			327.6	147.42	147.42	294.84		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	242.42							Fee Schedule																													294.84							Fee Schedule																																															
SYNTHESE 5.0 SCREW #212.212	278	RC	C1713	CPT				Both			453.6	204.12	204.12	408.24		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	335.66							Fee Schedule																													408.24							Fee Schedule																																															
SYNTHESE 5.0 SCREW #458.956S	278	RC	C1713	CPT				Both			510.3	229.64	229.64	459.27		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	377.62							Fee Schedule																													459.27							Fee Schedule																																															
SYNTHESE 5.0 SCREW 02.205.065	278	RC	C1713	CPT				Both			765.45	344.45	344.45	688.91		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	566.43							Fee Schedule																													688.91							Fee Schedule																																															
SYNTHESE 5.0 SCREW 02.205.070	278	RC	C1713	CPT				Both			878.85	395.48	395.48	790.97		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	650.35							Fee Schedule																													790.97							Fee Schedule																																															
SYNTHESE 5.0 SCREW 212.201	278	RC	C1713	CPT				Both			459.9	206.96	206.96	413.91		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	340.33							Fee Schedule																													413.91							Fee Schedule																																															
SYNTHESE 5.0 SCREW 212.202	278	RC	C1713	CPT				Both			459.9	206.96	206.96	413.91		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	340.33							Fee Schedule																													413.91							Fee Schedule																																															
SYNTHESE 5.0 SCREW 212.203	278	RC	C1713	CPT				Both			459.9	206.96	206.96	413.91		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	340.33							Fee Schedule																													413.91							Fee Schedule																																															
SYNTHESE 5.0 SCREW 212.204	278	RC	C1713	CPT				Both			459.9	206.96	206.96	413.91		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	340.33							Fee Schedule																													413.91							Fee Schedule																																															
SYNTHESE 5.0 SCREW 212.205	278	RC	C1713	CPT				Both			459.9	206.96	206.96	413.91		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	340.33							Fee Schedule																													413.91							Fee Schedule																																															
SYNTHESE 5.0 SCREW 212.206	278	RC	C1713	CPT				Both			459.9	206.96	206.96	413.91		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	340.33							Fee Schedule																													413.91							Fee Schedule																																															
SYNTHESE 5.0 SCREW 212.207	278	RC	C1713	CPT				Both			459.9	206.96	206.96	413.91		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	340.33							Fee Schedule																													413.91							Fee Schedule																																															
SYNTHESE 5.0 SCREW 212.208	278	RC	C1713	CPT				Both			459.9	206.96	206.96	413.91		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	340.33							Fee Schedule																													413.91							Fee Schedule																																															
SYNTHESE 5.0 SCREW 212.209	278	RC	C1713	CPT				Both			453.6	204.12	204.12	408.24		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	335.66							Fee Schedule																													408.24							Fee Schedule																																															
SYNTHESE 5.0 SCREW 212.210	278	RC	C1713	CPT				Both			453.6	204.12	204.12	408.24		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	335.66							Fee Schedule																													408.24							Fee Schedule																																															
SYNTHESE 5.0 SCREW 212.211	278	RC	C1713	CPT				Both			459.9	206.96	206.96	413.91		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	340.33							Fee Schedule																													413.91							Fee Schedule																																															
SYNTHESE 5.0 SCREW 212.213	278	RC	C1713	CPT				Both			657.3	295.79	295.79	591.57		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	486.4							Fee Schedule																													591.57							Fee Schedule																																															
SYNTHESE 5.0 SCREW 212.214	278	RC	C1713	CPT				Both			553.35	249.01	249.01	498.02		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	409.48							Fee Schedule																													498.02							Fee Schedule																																															
SYNTHESE 5.0 SCREW 212.216	278	RC	C1713	CPT				Both			553.35	249.01	249.01	498.02		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	409.48							Fee Schedule																													498.02							Fee Schedule																																															
SYNTHESE 5.0 SCREW 212.217	278	RC	C1713	CPT				Both			480.9	216.41	216.41	432.81		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	355.87							Fee Schedule																													432.81							Fee Schedule																																															
SYNTHESE 5.0 SCREW 212.218	278	RC	C1713	CPT				Both			553.35	249.01	249.01	498.02		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	409.48							Fee Schedule																													498.02							Fee Schedule																																															
SYNTHESE 5.0 SCREW 212.219	278	RC	C1713	CPT				Both			459.9	206.96	206.96	413.91		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	340.33							Fee Schedule																													413.91							Fee Schedule																																															
SYNTHESE 5.0 SCREW 212.220	278	RC	C1713	CPT				Both			477.75	214.99	214.99	429.98		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	353.54							Fee Schedule																													429.98							Fee Schedule																																															
SYNTHESE 5.0 SCREW 212.221	278	RC	C1713	CPT				Both			657.3	295.79	295.79	591.57		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	486.4							Fee Schedule																													591.57							Fee Schedule																																															
SYNTHESE 5.0 SCREW 222.538	278	RC	C1713	CPT				Both			408.45	183.8	183.8	367.61		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	302.25							Fee Schedule																													367.61							Fee Schedule																																															
SYNTHESE 5.0 SCREW 222.540	278	RC	C1713	CPT				Both			415.8	187.11	187.11	374.22		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	307.69							Fee Schedule																													374.22							Fee Schedule																																															
SYNTHESE 5.0 SCREW 222.545	278	RC	C1713	CPT				Both			528.15	237.67	237.67	475.34		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	390.83							Fee Schedule																													475.34							Fee Schedule																																															
SYNTHESE 5.0 SCREW 222.545	278	RC	C1713	CPT				Both			528.15	237.67	237.67	475.34		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	390.83							Fee Schedule																													475.34							Fee Schedule																																															
SYNTHESE 5.0 SCREW 75MM #212.224	278	RC	C1713	CPT				Both			453.6	204.12	204.12	408.24		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	335.66							Fee Schedule																													408.24							Fee Schedule																																															
SYNTHESE 7.3 CANN SCREW 32MM 209.845	278	RC	C1713	CPT				Both			708.75	318.94	318.94	637.88		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	524.48							Fee Schedule																													637.88							Fee Schedule																																															
SYNTHESE 7.3 CANN SCREW 32MM 209.850	278	RC	C1713	CPT				Both			564.9	254.21	254.21	508.41		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	418.03							Fee Schedule																													508.41							Fee Schedule																																															
SYNTHESE 7.3 CANN SCREW 32MM 209.855	278	RC	C1713	CPT				Both			760.2	342.09	342.09	684.18		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	562.55							Fee Schedule																													684.18							Fee Schedule																																															
SYNTHESE 7.3 CANN SCREW 32MM 209.860	278	RC	C1713	CPT				Both			1125.6	506.52	506.52	1013.04		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	832.94							Fee Schedule																													1013.04							Fee Schedule																																															
SYNTHESE 7.3 CANN SCREW 32MM 209.865	278	RC	C1713	CPT				Both			1052.1	473.45	473.45	946.89		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	778.55							Fee Schedule																													946.89							Fee Schedule																																															
SYNTHESE 7.3 CANN SCREW 32MM 209.875	278	RC	C1713	CPT				Both			1030	463.5	463.5	927		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	762.2							Fee Schedule																													927							Fee Schedule																																															
SYNTHESE 7.3 CANN SCREW 32MM 209.880	278	RC	C1713	CPT				Both			1030	463.5	463.5	927		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	762.2							Fee Schedule																													927							Fee Schedule																																															
SYNTHESE 7.3 CANN SCREW 32MM 209.885	278	RC	C1713	CPT				Both			1314	591.3	591.3	1182.6		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	972.36							Fee Schedule																													1182.6							Fee Schedule																																															
SYNTHESE 7.3 CANN SCREW 32MM 209.885	278	RC	C1713	CPT				Both			564.9	254.21	254.21	508.41		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	418.03							Fee Schedule																													508.41							Fee Schedule																																															
SYNTHESE 7.3 CANN SCREW 32MM 209.890	278	RC	C1713	CPT				Both			1081	486.45	486.45	972.9		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	799.94							Fee Schedule																													972.9							Fee Schedule																																															
SYNTHESE 7.3 CANN SCREW 32MM 209.895	278	RC	C1713	CPT				Both			1081	486.45	486.45	972.9		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	799.94							Fee Schedule																													972.9							Fee Schedule																																															
SYNTHESE 7.3 CANN SCREW 32MM 209.900	278	RC	C1713	CPT				Both			1081	486.45	486.45	972.9		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	799.94							Fee Schedule																													972.9							Fee Schedule																																															
SYNTHESE 7.3 CANN SCREW 32MM 209.905	278	RC	C1713	CPT				Both			1205.4	542.43	542.43	1084.86		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	892							Fee Schedule																													1084.86							Fee Schedule																																															
SYNTHESE 7.3 CANN SCREW 32MM 209.910	278	RC	C1713	CPT				Both			1020.6	459.27	459.27	918.54		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	755.24							Fee Schedule																													918.54							Fee Schedule																																															
SYNTHESE 7.3 CANN SCREW 32MM 209.915	278	RC	C1713	CPT				Both			1205.4	542.43	542.43	1084.86		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	892							Fee Schedule																													1084.86							Fee Schedule																																															
SYNTHESE 7.3 CANN SCREW 32MM 209.920	278	RC	C1713	CPT				Both			1205.4	542.43	542.43	1084.86		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	892							Fee Schedule																													1084.86							Fee Schedule																																															
SYNTHESE 7.3 CANN SCREW 32MM 209.925	278	RC	C1713	CPT				Both			1205.4	542.43	542.43	1084.86		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	892							Fee Schedule																													1084.86							Fee Schedule																																															
SYNTHESE 7.3 CANN SCREW 32MM 209.930	278	RC	C1713	CPT				Both			564.9	254.21	254.21	508.41		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	418.03							Fee Schedule																													508.41							Fee Schedule																																															
SYNTHESE 7.3 CANN SCREW 32MM 209.935	278	RC	C1713	CPT				Both			564.9	254.21	254.21	508.41		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	418.03							Fee Schedule																													508.41							Fee Schedule																																															
SYNTHESE 7.3 CANN SCREW 32MM 209.940	278	RC	C1713	CPT				Both			564.9	254.21	254.21	508.41		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	418.03							Fee Schedule																													508.41							Fee Schedule																																															
SYNTHESE 7.3 CANN SCREW 32MM 209.945	278	RC	C1713	CPT				Both			564.9	254.21	254.21	508.41		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	418.03							Fee Schedule																													508.41							Fee Schedule																																															
SYNTHESE 7.3 CANN SCREW 32MM 209.950	278	RC	C1713	CPT				Both			564.9	254.21	254.21	508.41		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	418.03							Fee Schedule																													508.41							Fee Schedule																																															
SYNTHESE 7.3 SCREW 222.571	278	RC	C1713	CPT				Both			613.2	275.94	275.94	551.88		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	453.77							Fee Schedule																													551.88							Fee Schedule																																															
SYNTHESE 7.3 SCREW 222.645	278	RC	C1713	CPT				Both			544.95	245.23	245.23	490.46		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	403.26							Fee Schedule																													490.46							Fee Schedule																																															
SYNTHESE 7.3 SCREW 222.646	278	RC	C1713	CPT				Both			703.5	316.58	316.58	633.15		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	520.59							Fee Schedule																													633.15							Fee Schedule																																															
SYNTHESE 7.3MM CANN SCREW 16MM 208.830	278	RC	C1713	CPT				Both			564.9	254.21	254.21	508.41		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	418.03							Fee Schedule																													508.41							Fee Schedule																																															
SYNTHESE 7.3MM CANN SCREW 16MM 208.835	278	RC	C1713	CPT				Both			564.9	254.21	254.21	508.41		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	418.03							Fee Schedule																													508.41							Fee Schedule																																															
SYNTHESE 7.3MM CANN SCREW 16MM 208.840	278	RC	C1713	CPT				Both			760.2	342.09	342.09	684.18		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	562.55							Fee Schedule																													684.18							Fee Schedule																																															
SYNTHESE 7.3MM CANN SCREW 16MM 208.845	278	RC	C1713	CPT				Both			793.8	357.21	357.21	714.42		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	587.41							Fee Schedule																													714.42							Fee Schedule																																															
SYNTHESE 7.3MM CANN SCREW 16MM 208.850	278	RC	C1713	CPT				Both			760.2	342.09	342.09	684.18		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	562.55							Fee Schedule																													684.18							Fee Schedule																																															
SYNTHESE 7.3MM CANN SCREW 16MM 208.855	278	RC	C1713	CPT				Both			892.5	401.63	401.63	803.25		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	660.45							Fee Schedule																													803.25							Fee Schedule																																															
SYNTHESE 7.3MM CANN SCREW 16MM 208.860	278	RC	C1713	CPT				Both			760.2	342.09	342.09	684.18		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	562.55							Fee Schedule																													684.18							Fee Schedule																																															
SYNTHESE 7.3MM CANN SCREW 16MM 208.865	278	RC	C1713	CPT				Both			891.45	401.15	401.15	802.31		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	659.67							Fee Schedule																													802.31							Fee Schedule																																															
SYNTHESE 7.3MM CANN SCREW 16MM 208.870	278	RC	C1713	CPT				Both			1081	486.45	486.45	972.9		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	799.94							Fee Schedule																													972.9							Fee Schedule																																															
SYNTHESE 7.3MM CANN SCREW 16MM 208.880	278	RC	C1713	CPT				Both			1081	486.45	486.45	972.9		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	799.94							Fee Schedule																													972.9							Fee Schedule																																															
SYNTHESE 7.3MM CANN SCREW 16MM 208.885	278	RC	C1713	CPT				Both			1081	486.45	486.45	972.9		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	799.94							Fee Schedule																													972.9							Fee Schedule																																															
SYNTHESE 7.3MM CANN SCREW 16MM 208.890	278	RC	C1713	CPT				Both			1030	463.5	463.5	927		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	762.2							Fee Schedule																													927							Fee Schedule																																															
SYNTHESE 7.3MM CANN SCREW 16MM 208.895	278	RC	C1713	CPT				Both			1081	486.45	486.45	972.9		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	799.94							Fee Schedule																													972.9							Fee Schedule																																															
SYNTHESE 7.3MM CANN SCREW 16MM 208.900	278	RC	C1713	CPT				Both			1081	486.45	486.45	972.9		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	799.94							Fee Schedule																													972.9							Fee Schedule																																															
SYNTHESE 7.3MM CANN SCREW 16MM 208.905	278	RC	C1713	CPT				Both			564.9	254.21	254.21	508.41		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	418.03							Fee Schedule																													508.41							Fee Schedule																																															
SYNTHESE 7.3MM CANN SCREW 16MM 208.910	278	RC	C1713	CPT				Both			564.9	254.21	254.21	508.41		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	418.03							Fee Schedule																													508.41							Fee Schedule																																															
SYNTHESE 7.3MM CANN SCREW 16MM 208.915	278	RC	C1713	CPT				Both			564.9	254.21	254.21	508.41		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	418.03							Fee Schedule																													508.41							Fee Schedule																																															
SYNTHESE 7.3MM CANN SCREW 16MM 208.920	278	RC	C1713	CPT				Both			564.9	254.21	254.21	508.41		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	418.03							Fee Schedule																													508.41							Fee Schedule																																															
SYNTHESE 7.3MM CANN SCREW 16MM 208.925	278	RC	C1713	CPT				Both			564.9	254.21	254.21	508.41		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	418.03							Fee Schedule																													508.41							Fee Schedule																																															
SYNTHESE 7.3MM CANN SCREW 16MM 208.930	278	RC	C1713	CPT				Both			564.9	254.21	254.21	508.41		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	418.03							Fee Schedule																													508.41							Fee Schedule																																															
SYNTHESE 7.3MM CANN SCREW 16MM 208.935	278	RC	C1713	CPT				Both			564.9	254.21	254.21	508.41		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	418.03							Fee Schedule																													508.41							Fee Schedule																																															
SYNTHESE 7.3MM CANN SCREW 16MM 208.940	278	RC	C1713	CPT				Both			564.9	254.21	254.21	508.41		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	418.03							Fee Schedule																													508.41							Fee Schedule																																															
SYNTHESE 7.3MM CANN SCREW 16MM 208.945	278	RC	C1713	CPT				Both			538.65	242.39	242.39	484.79		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	398.6							Fee Schedule																													484.79							Fee Schedule																																															
SYNTHESE 7.3MM CANN SCREW 16MM 208.950	278	RC	C1713	CPT				Both			564.9	254.21	254.21	508.41		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	418.03							Fee Schedule																													508.41							Fee Schedule																																															
SYNTHESE 8 HOLE PLATE # 236.509	278	RC	C1713	CPT				Both			3260.25	1467.11	1467.11	2934.23		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	2412.59							Fee Schedule																													2934.23							Fee Schedule																																															
SYNTHESE 8 HOLE PLATE 222.658	278	RC	C1713	CPT				Both			6997.2	3148.74	3148.74	6297.48		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	5177.93							Fee Schedule																													6297.48							Fee Schedule																																															
SYNTHESE 8 HOLE PLATE 223.581	278	RC	C1713	CPT				Both			1734	780.3	780.3	1560.6		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1283.16							Fee Schedule																													1560.6							Fee Schedule																																															
SYNTHESE CANN. SCREW # 02.240.252	278	RC	C1713	CPT				Both			551.25	248.06	248.06	496.13		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	407.93							Fee Schedule																													496.13							Fee Schedule																																															
SYNTHESE CANNULATED LOCKING SCREW 222.5	278	RC	C1713	CPT				Both			788.55	354.85	354.85	709.7		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	583.53							Fee Schedule																													709.7							Fee Schedule																																															
SYNTHESE CANNULATED LOCKING SCREW 222.57	278	RC	C1713	CPT				Both			788.55	354.85	354.85	709.7		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	583.53							Fee Schedule																													709.7							Fee Schedule																																															
SYNTHESE CARBON ROD 395.782	278	RC	C1713	CPT				Both			378	170.1	170.1	340.2		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	279.72							Fee Schedule																													340.2							Fee Schedule																																															
SYNTHESE CARBON RODS #395.105	278	RC						Both			89.25	40.16	40.16	80.33		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	66.05							Fee Schedule																													80.33							Fee Schedule																																															
SYNTHESE CLOVERLEAF PLATE 10 HOLE 241.83	278	RC	C1713	CPT				Both			578.55	260.35	260.35	520.7		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	428.13							Fee Schedule																													520.7							Fee Schedule																																															
SYNTHESE CLOVERLEAF PLATE 241.84	278	RC	C1713	CPT				Both			619.5	278.78	278.78	557.55		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	458.43							Fee Schedule																													557.55							Fee Schedule																																															
SYNTHESE DBX MIX 15CC 058.150	278	RC	C9356	CPT				Both			4405.8	1982.61	1982.61	3965.22		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	3260.29							Fee Schedule																													3965.22							Fee Schedule																																															
SYNTHESE DBX MIX 2.5CC 058025	278	RC	C9359	CPT				Both			1884.75	848.14	848.14	1696.28		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1394.72							Fee Schedule																													1696.28							Fee Schedule																																															
SYNTHESE DBX MIX 5.0 058050	278	RC	C9359	CPT				Both			3257.1	1465.7	1465.7	2931.39		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	2410.25							Fee Schedule																													2931.39							Fee Schedule																																															
SYNTHESE DBX PUTTY 10CC 038100	278	RC	C9359	CPT				Both			4147.5	1866.38	1866.38	3732.75		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	3069.15							Fee Schedule																													3732.75							Fee Schedule																																															
SYNTHESE DBX PUTTY 2.5CC 038025	278	RC	C9359	CPT				Both			1633.8	735.21	735.21	1470.42		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1209.01							Fee Schedule																													1470.42							Fee Schedule																																															
SYNTHESE DHS LAG SCREW 100MM 280.301	278	RC	C1713	CPT				Both			737.1	331.7	331.7	663.39		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	545.45							Fee Schedule																													663.39							Fee Schedule																																															
SYNTHESE DHS LAG SCREW 105MM 280.305	278	RC	C1713	CPT				Both			680.4	306.18	306.18	612.36		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	503.5							Fee Schedule																													612.36							Fee Schedule																																															
SYNTHESE DHS LAG SCREW 110MM 280.310	278	RC	C1713	CPT				Both			680.4	306.18	306.18	612.36		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	503.5							Fee Schedule																													612.36							Fee Schedule																																															
SYNTHESE DHS LAG SCREW 115MM 280.315	278	RC	C1713	CPT				Both			680.4	306.18	306.18	612.36		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	503.5							Fee Schedule																													612.36							Fee Schedule																																															
SYNTHESE DHS LAG SCREW 120MM 280.320	278	RC	C1713	CPT				Both			680.4	306.18	306.18	612.36		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	503.5							Fee Schedule																													612.36							Fee Schedule																																															
SYNTHESE DHS LAG SCREW 125MM 280.325	278	RC	C1713	CPT				Both			680.4	306.18	306.18	612.36		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	503.5							Fee Schedule																													612.36							Fee Schedule																																															
SYNTHESE DHS LAG SCREW 130MM 280.330	278	RC	C1713	CPT				Both			680.4	306.18	306.18	612.36		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	503.5							Fee Schedule																													612.36							Fee Schedule																																															
SYNTHESE DHS LAG SCREW 135MM 280.335	278	RC	C1713	CPT				Both			680.4	306.18	306.18	612.36		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	503.5							Fee Schedule																													612.36							Fee Schedule																																															
SYNTHESE DHS LAG SCREW 140MM  280.340	278	RC	C1713	CPT				Both			680.4	306.18	306.18	612.36		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	503.5							Fee Schedule																													612.36							Fee Schedule																																															
SYNTHESE DHS LAG SCREW 145MM 280.345	278	RC	C1713	CPT				Both			680.4	306.18	306.18	612.36		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	503.5							Fee Schedule																													612.36							Fee Schedule																																															
SYNTHESE DHS LAG SCREW 65MM 280.265	278	RC	C1713	CPT				Both			680.4	306.18	306.18	612.36		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	503.5							Fee Schedule																													612.36							Fee Schedule																																															
SYNTHESE DHS LAG SCREW 70MM 280.270	278	RC	C1713	CPT				Both			680.4	306.18	306.18	612.36		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	503.5							Fee Schedule																													612.36							Fee Schedule																																															
SYNTHESE DHS LAG SCREW 75MM 280.275	278	RC	C1713	CPT				Both			680.4	306.18	306.18	612.36		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	503.5							Fee Schedule																													612.36							Fee Schedule																																															
SYNTHESE DHS LAG SCREW 80MM 280.280	278	RC	C1713	CPT				Both			737.1	331.7	331.7	663.39		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	545.45							Fee Schedule																													663.39							Fee Schedule																																															
SYNTHESE DHS LAG SCREW 85MM 280.285	278	RC	C1713	CPT				Both			680.4	306.18	306.18	612.36		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	503.5							Fee Schedule																													612.36							Fee Schedule																																															
SYNTHESE DHS LAG SCREW 90MM 280.290	278	RC	C1713	CPT				Both			1207.5	543.38	543.38	1086.75		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	893.55							Fee Schedule																													1086.75							Fee Schedule																																															
SYNTHESE DHS LAG SCREW 95MM 280.295	278	RC	C1713	CPT				Both			680.4	306.18	306.18	612.36		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	503.5							Fee Schedule																													612.36							Fee Schedule																																															
SYNTHESE DHS/DCS 1 STEP LAG 280.285	278	RC	C1713	CPT				Both			930.3	418.64	418.64	837.27		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	688.42							Fee Schedule																													837.27							Fee Schedule																																															
SYNTHESE DISTAL PLATE #442.493	278	RC	C1713	CPT				Both			2625	1181.25	1181.25	2362.5		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1942.5							Fee Schedule																													2362.5							Fee Schedule																																															
SYNTHESE DISTRACTOR DISTAL 394.075	278	RC	C1713	CPT				Both			1269.45	571.25	571.25	1142.51		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	939.39							Fee Schedule																													1142.51							Fee Schedule																																															
SYNTHESE DRILL BIT 2.8 MM 310.288	270	RC						Both			471	211.95	211.95	423.9	306.15							Fee Schedule		348.54							Fee Schedule																													423.9							Fee Schedule																																															
SYNTHESE DRILL BIT 310.37	270	RC						Both			351.75	158.29	158.29	316.58	228.64							Fee Schedule		260.3							Fee Schedule																													316.58							Fee Schedule																																															
SYNTHESE DRILL BIT 310.44	272	RC						Both			278.25	125.21	125.21	250.43	180.86							Fee Schedule		205.91							Fee Schedule																													250.43							Fee Schedule																																															
SYNTHESE DRILL BIT 310.48	270	RC						Both			547.05	246.17	246.17	492.35	355.58							Fee Schedule		404.82							Fee Schedule																													492.35							Fee Schedule																																															
SYNTHESE END CAP #456.311	278	RC	C1713	CPT				Both			510.3	229.64	229.64	459.27		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	377.62							Fee Schedule																													459.27							Fee Schedule																																															
SYNTHESE END CAP #456.312	278	RC	C1713	CPT				Both			510.3	229.64	229.64	459.27		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	377.62							Fee Schedule																													459.27							Fee Schedule																																															
SYNTHESE END CAP #456.313	278	RC	C1713	CPT				Both			510.3	229.64	229.64	459.27		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	377.62							Fee Schedule																													459.27							Fee Schedule																																															
SYNTHESE END CAP #462.660	278	RC	C1713	CPT				Both			488.25	219.71	219.71	439.43		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	361.31							Fee Schedule																													439.43							Fee Schedule																																															
SYNTHESE END CAP 458.10	278	RC	C1713	CPT				Both			259.35	116.71	116.71	233.42		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	191.92							Fee Schedule																													233.42							Fee Schedule																																															
SYNTHESE EXPRESS SWHA 000.00	272	RC						Both			159.6	71.82	71.82	143.64	103.74							Fee Schedule		118.1							Fee Schedule																													143.64							Fee Schedule																																															
SYNTHESE FEMORAL GUIDE ROD  355.041S	272	RC						Both			322.35	145.06	145.06	290.12	209.53							Fee Schedule		238.54							Fee Schedule																													290.12							Fee Schedule																																															
SYNTHESE FEMORAL NAIL CANN.TI 474.038S	278	RC	C1713	CPT				Both			2449.65	1102.34	1102.34	2204.69		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1812.74							Fee Schedule																													2204.69							Fee Schedule																																															
SYNTHESE FIBULAR PLATE #04.112.138	278	RC	C1713	CPT				Both			2778.3	1250.24	1250.24	2500.47		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	2055.94							Fee Schedule																													2500.47							Fee Schedule																																															
SYNTHESE FIXATION NAIL 456.314	278	RC	C1713	CPT				Both			4060.35	1827.16	1827.16	3654.32		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	3004.66							Fee Schedule																													3654.32							Fee Schedule																																															
SYNTHESE FIXATION NAIL 456.317	278	RC	C1713	CPT				Both			4060.35	1827.16	1827.16	3654.32		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	3004.66							Fee Schedule																													3654.32							Fee Schedule																																															
SYNTHESE FIXATION NAIL 456.318	278	RC	C1713	CPT				Both			4060.35	1827.16	1827.16	3654.32		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	3004.66							Fee Schedule																													3654.32							Fee Schedule																																															
SYNTHESE FIXATION NAIL 456.318S	278	RC	C1713	CPT				Both			4938.15	2222.17	2222.17	4444.34		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	3654.23							Fee Schedule																													4444.34							Fee Schedule																																															
SYNTHESE FIXATION NAIL 456.318S	278	RC	C1713	CPT				Both			4938.15	2222.17	2222.17	4444.34		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	3654.23							Fee Schedule																													4444.34							Fee Schedule																																															
SYNTHESE FIXATION NAIL 456.321	278	RC	C1713	CPT				Both			4060.35	1827.16	1827.16	3654.32		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	3004.66							Fee Schedule																													3654.32							Fee Schedule																																															
SYNTHESE FIXATION NAIL 456.412S	278	RC	C1713	CPT				Both			5591.25	2516.06	2516.06	5032.13		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	4137.53							Fee Schedule																													5032.13							Fee Schedule																																															
SYNTHESE FIXATION NAIL 456.413S	278	RC	C1713	CPT				Both			5591.25	2516.06	2516.06	5032.13		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	4137.53							Fee Schedule																													5032.13							Fee Schedule																																															
SYNTHESE FIXATION NAIL 456.414S	278	RC	C1713	CPT				Both			8161.65	3672.74	3672.74	7345.49		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	6039.62							Fee Schedule																													7345.49							Fee Schedule																																															
SYNTHESE FIXATION NAIL 456.415S	278	RC	C1713	CPT				Both			5839.05	2627.57	2627.57	5255.15		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	4320.9							Fee Schedule																													5255.15							Fee Schedule																																															
SYNTHESE FIXATION NAIL 456.416S	278	RC	C1713	CPT				Both			7419.3	3338.69	3338.69	6677.37		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	5490.28							Fee Schedule																													6677.37							Fee Schedule																																															
SYNTHESE FIXATION NAIL 456.417S	278	RC	C1713	CPT				Both			6932.1	3119.45	3119.45	6238.89		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	5129.75							Fee Schedule																													6238.89							Fee Schedule																																															
SYNTHESE FIXATION NAIL 456.420S	278	RC	C1713	CPT				Both			7419.3	3338.69	3338.69	6677.37		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	5490.28							Fee Schedule																													6677.37							Fee Schedule																																															
SYNTHESE FIXTION PIN 294.30	278	RC	C1713	CPT				Both			176.4	79.38	79.38	158.76		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	130.54							Fee Schedule																													158.76							Fee Schedule																																															
SYNTHESE GUIDE WIRE 292.68	272	RC	C1769	CPT				Both			198	89.1	89.1	178.2	154.26							Fee Schedule		146.52							Fee Schedule																													178.2							Fee Schedule																																															
SYNTHESE GUIDE WIRE 310.243	272	RC	C1769	CPT				Both			300.3	135.14	135.14	270.27	154.26							Fee Schedule		222.22							Fee Schedule																													270.27							Fee Schedule																																															
SYNTHESE GUIDE WIRES #900.722	272	RC	C1769	CPT				Both			129	58.05	58.05	154.26	154.26							Fee Schedule		95.46							Fee Schedule																													116.1							Fee Schedule																																															
SYNTHESE GUIDE WIRES 324.174	272	RC	C1769	CPT				Both			414.75	186.64	154.26	373.28	154.26							Fee Schedule		306.92							Fee Schedule																													373.28							Fee Schedule																																															
SYNTHESE GUIDE WIRES 900.601	272	RC	C1769	CPT				Both			225	101.25	101.25	202.5	154.26							Fee Schedule		166.5							Fee Schedule																													202.5							Fee Schedule																																															
SYNTHESE HELICAL BLADE 100MM 456.305	278	RC	C1713	CPT				Both			2964.15	1333.87	1333.87	2667.74		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	2193.47							Fee Schedule																													2667.74							Fee Schedule																																															
SYNTHESE HELICAL BLADE 105MM  456.306	278	RC	C1713	CPT				Both			2262.75	1018.24	1018.24	2036.48		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1674.44							Fee Schedule																													2036.48							Fee Schedule																																															
SYNTHESE HELICAL BLADE 110MM 456.307	278	RC	C1713	CPT				Both			2668.05	1200.62	1200.62	2401.25		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1974.36							Fee Schedule																													2401.25							Fee Schedule																																															
SYNTHESE HELICAL BLADE 115MM 456.308	278	RC	C1713	CPT				Both			1927.8	867.51	867.51	1735.02		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1426.57							Fee Schedule																													1735.02							Fee Schedule																																															
SYNTHESE HELICAL BLADE 120MM 456.309	278	RC	C1713	CPT				Both			1927.8	867.51	867.51	1735.02		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1426.57							Fee Schedule																													1735.02							Fee Schedule																																															
SYNTHESE HELICAL BLADE 80MM 456.301	278	RC	C1713	CPT				Both			3934.35	1770.46	1770.46	3540.92		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	2911.42							Fee Schedule																													3540.92							Fee Schedule																																															
SYNTHESE HELICAL BLADE 85MM 04.038.380	278	RC	C1713	CPT				Both			3247	1461.15	1461.15	2922.3		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	2402.78							Fee Schedule																													2922.3							Fee Schedule																																															
SYNTHESE HELICAL BLADE 85MM 04.038.385	278	RC	C1713	CPT				Both			3247	1461.15	1461.15	2922.3		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	2402.78							Fee Schedule																													2922.3							Fee Schedule																																															
SYNTHESE HELICAL BLADE 85MM 456.302	278	RC	C1713	CPT				Both			1968.75	885.94	885.94	1771.88		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1456.88							Fee Schedule																													1771.88							Fee Schedule																																															
SYNTHESE HELICAL BLADE 90MM 456.302S	278	RC	C1713	CPT				Both			1927.8	867.51	867.51	1735.02		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1426.57							Fee Schedule																													1735.02							Fee Schedule																																															
SYNTHESE HELICAL BLADE 90MM 456.303	278	RC	C1713	CPT				Both			1927.8	867.51	867.51	1735.02		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1426.57							Fee Schedule																													1735.02							Fee Schedule																																															
SYNTHESE HELICAL BLADE 95MM 456.304	278	RC	C1713	CPT				Both			3934.35	1770.46	1770.46	3540.92		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	2911.42							Fee Schedule																													3540.92							Fee Schedule																																															
SYNTHESE HELIX BLADE 80MM # 282.235	278	RC	C1713	CPT				Both			1011.15	455.02	455.02	910.04		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	748.25							Fee Schedule																													910.04							Fee Schedule																																															
SYNTHESE HOLDING CLAMP #395.125	278	RC	C1713	CPT				Both			1648.5	741.83	741.83	1483.65		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1219.89							Fee Schedule																													1483.65							Fee Schedule																																															
SYNTHESE IM NAIL#462.923S	278	RC	C1713	CPT				Both			4224.15	1900.87	1900.87	3801.74		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	3125.87							Fee Schedule																													3801.74							Fee Schedule																																															
SYNTHESE K WIRE 492.12	278	RC	C1713	CPT				Both			46	20.7	20.7	41.4		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	34.04							Fee Schedule																													41.4							Fee Schedule																																															
SYNTHESE LCD PLATE 6 HOLE #241.361	278	RC	C1713	CPT				Both			774.6	348.57	348.57	697.14		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	573.2							Fee Schedule																													697.14							Fee Schedule																																															
SYNTHESE LCP IMPACTOR CAP #338.348	278	RC	C1713	CPT				Both			460.95	207.43	207.43	414.86		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	341.1							Fee Schedule																													414.86							Fee Schedule																																															
SYNTHESE LCP PLATE # 02.112.527	278	RC	C1713	CPT				Both			4777.5	2149.88	2149.88	4299.75		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	3535.35							Fee Schedule																													4299.75							Fee Schedule																																															
SYNTHESE LCP PLATE 02.001.322	278	RC	C1713	CPT				Both			4403.7	1981.67	1981.67	3963.33		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	3258.74							Fee Schedule																													3963.33							Fee Schedule																																															
SYNTHESE LCP SIDEPLATE # 282.602	278	RC	C1713	CPT				Both			1741.95	783.88	783.88	1567.76		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1289.04							Fee Schedule																													1567.76							Fee Schedule																																															
SYNTHESE LCP SIDEPLATE # 282.612	278	RC	C1713	CPT				Both			1741.95	783.88	783.88	1567.76		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1289.04							Fee Schedule																													1567.76							Fee Schedule																																															
SYNTHESE LOCK SCREW S.T. # 212.215	278	RC	C1713	CPT				Both			449.4	202.23	202.23	404.46		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	332.56							Fee Schedule																													404.46							Fee Schedule																																															
SYNTHESE LOCKING BOLT 3.9MM  458.30	278	RC	C1713	CPT				Both			374.85	168.68	168.68	337.37		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	277.39							Fee Schedule																													337.37							Fee Schedule																																															
SYNTHESE LOCKING BOLT 3.9MM  458.34	278	RC	C1713	CPT				Both			374.85	168.68	168.68	337.37		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	277.39							Fee Schedule																													337.37							Fee Schedule																																															
SYNTHESE LOCKING BOLT 3.9MM  458.36	278	RC	C1713	CPT				Both			374.85	168.68	168.68	337.37		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	277.39							Fee Schedule																													337.37							Fee Schedule																																															
SYNTHESE LOCKING SCREW 422.391	278	RC	C1713	CPT				Both			663.6	298.62	298.62	597.24		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	491.06							Fee Schedule																													597.24							Fee Schedule																																															
SYNTHESE LOCKING SCREW 422.392	278	RC	C1713	CPT				Both			663.6	298.62	298.62	597.24		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	491.06							Fee Schedule																													597.24							Fee Schedule																																															
SYNTHESE LOCKING SCREW 422.393	278	RC	C1713	CPT				Both			663.6	298.62	298.62	597.24		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	491.06							Fee Schedule																													597.24							Fee Schedule																																															
SYNTHESE LOCKING SCREW 422.395	278	RC	C1713	CPT				Both			663.6	298.62	298.62	597.24		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	491.06							Fee Schedule																													597.24							Fee Schedule																																															
SYNTHESE LOCKING SCREW 422.396	278	RC	C1713	CPT				Both			663.6	298.62	298.62	597.24		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	491.06							Fee Schedule																													597.24							Fee Schedule																																															
SYNTHESE LOCKING SCREW 458.826	278	RC	C1713	CPT				Both			488.25	219.71	219.71	439.43		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	361.31							Fee Schedule																													439.43							Fee Schedule																																															
SYNTHESE LOCKING SCREW 458.942	278	RC	C1713	CPT				Both			808.5	363.83	363.83	727.65		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	598.29							Fee Schedule																													727.65							Fee Schedule																																															
SYNTHESE MALLELO SCREW #215.055	278	RC	C1713	CPT				Both			85.05	38.27	38.27	76.55		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	62.94							Fee Schedule																													76.55							Fee Schedule																																															
SYNTHESE MALLELO SCREW #215.060	278	RC	C1713	CPT				Both			85.05	38.27	38.27	76.55		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	62.94							Fee Schedule																													76.55							Fee Schedule																																															
SYNTHESE MEASURING DEVICE #319.15	270	RC						Both			453.6	204.12	204.12	408.24	294.84							Fee Schedule		335.66							Fee Schedule																													408.24							Fee Schedule																																															
SYNTHESE NARROW PLATE 224.541	278	RC	C1713	CPT				Both			1095.15	492.82	492.82	985.64		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	810.41							Fee Schedule																													985.64							Fee Schedule																																															
SYNTHESE NARROW PLATE 224.551	278	RC	C1713	CPT				Both			1839.6	827.82	827.82	1655.64		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1361.3							Fee Schedule																													1655.64							Fee Schedule																																															
SYNTHESE NARROW PLATE 224.561	278	RC	C1713	CPT				Both			1234.8	555.66	555.66	1111.32		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	913.75							Fee Schedule																													1111.32							Fee Schedule																																															
SYNTHESE NARROW PLATE 224.571	278	RC	C1713	CPT				Both			1435.35	645.91	645.91	1291.82		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1062.16							Fee Schedule																													1291.82							Fee Schedule																																															
SYNTHESE NARROW PLATE 224.581	278	RC	C1713	CPT				Both			2384.55	1073.05	1073.05	2146.1		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1764.57							Fee Schedule																													2146.1							Fee Schedule																																															
SYNTHESE NARROW PLATE 224.591	278	RC	C1713	CPT				Both			1582.35	712.06	712.06	1424.12		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1170.94							Fee Schedule																													1424.12							Fee Schedule																																															
SYNTHESE NARROW PLATE 224.601	278	RC	C1713	CPT				Both			1634.85	735.68	735.68	1471.37		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1209.79							Fee Schedule																													1471.37							Fee Schedule																																															
SYNTHESE NARROW PLATE 224.611	278	RC	C1713	CPT				Both			1854.3	834.44	834.44	1668.87		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1372.18							Fee Schedule																													1668.87							Fee Schedule																																															
SYNTHESE NARROW PLATE 224.621	278	RC	C1713	CPT				Both			1990.8	895.86	895.86	1791.72		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1473.19							Fee Schedule																													1791.72							Fee Schedule																																															
SYNTHESE NARROW PLATE 224.641	278	RC	C1713	CPT				Both			2257.5	1015.88	1015.88	2031.75		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1670.55							Fee Schedule																													2031.75							Fee Schedule																																															
SYNTHESE NARROW PLATE 224.661	278	RC	C1713	CPT				Both			2614.5	1176.53	1176.53	2353.05		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1934.73							Fee Schedule																													2353.05							Fee Schedule																																															
SYNTHESE OBLIQUE T PLATE 241.23	278	RC	C1713	CPT				Both			408.45	183.8	183.8	367.61		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	302.25							Fee Schedule																													367.61							Fee Schedule																																															
SYNTHESE OBLIQUE T PLATE 241.24	278	RC	C1713	CPT				Both			435.75	196.09	196.09	392.18		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	322.46							Fee Schedule																													392.18							Fee Schedule																																															
SYNTHESE OBLIQUE T PLATE 241.25	278	RC	C1713	CPT				Both			449.4	202.23	202.23	404.46		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	332.56							Fee Schedule																													404.46							Fee Schedule																																															
SYNTHESE PLATE # 02.123.020	278	RC	C1713	CPT				Both			5570.25	2506.61	2506.61	5013.23		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	4121.99							Fee Schedule																													5013.23							Fee Schedule																																															
SYNTHESE PLATE # 02.123.021	278	RC	C1713	CPT				Both			6353.55	2859.1	2859.1	5718.2		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	4701.63							Fee Schedule																													5718.2							Fee Schedule																																															
SYNTHESE PLATE # 02.123.041	278	RC	C1713	CPT				Both			5092.5	2291.63	2291.63	4583.25		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	3768.45							Fee Schedule																													4583.25							Fee Schedule																																															
SYNTHESE PLATE #442.494	278	RC	C1713	CPT				Both			2778.3	1250.24	1250.24	2500.47		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	2055.94							Fee Schedule																													2500.47							Fee Schedule																																															
SYNTHESE PLATE 442.507	278	RC	C1713	CPT				Both			1519.35	683.71	683.71	1367.42		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1124.32							Fee Schedule																													1367.42							Fee Schedule																																															
SYNTHESE REAMING ROD  #351.706S	272	RC						Both			659	296.55	296.55	593.1	428.35							Fee Schedule		487.66							Fee Schedule																													593.1							Fee Schedule																																															
SYNTHESE RECON PLATE 245.051	278	RC	C1713	CPT				Both			998.55	449.35	449.35	898.7		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	738.93							Fee Schedule																													898.7							Fee Schedule																																															
SYNTHESE RIGHT 6 HOLE PLATE 222.524	278	RC	C1713	CPT				Both			2769.9	1246.46	1246.46	2492.91		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	2049.73							Fee Schedule																													2492.91							Fee Schedule																																															
SYNTHESE RING 3/4 165MM ID 393.736	278	RC	C1713	CPT				Both			1554	699.3	699.3	1398.6		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1149.96							Fee Schedule																													1398.6							Fee Schedule																																															
SYNTHESE RING TO ROD CLAMP 393.436	278	RC	C1713	CPT				Both			2983.05	1342.37	1342.37	2684.75		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	2207.46							Fee Schedule																													2684.75							Fee Schedule																																															
SYNTHESE RUSH ROD C-36	278	RC	C1713	CPT				Both			453.6	204.12	204.12	408.24		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	335.66							Fee Schedule																													408.24							Fee Schedule																																															
SYNTHESE SCHANZ SCREW 294.785	278	RC	C1713	CPT				Both			850.5	382.73	382.73	765.45		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	629.37							Fee Schedule																													765.45							Fee Schedule																																															
SYNTHESE SCREW # 02.212.054	278	RC	C1713	CPT				Both			567	255.15	255.15	510.3		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	419.58							Fee Schedule																													510.3							Fee Schedule																																															
SYNTHESE SCREW # 02.212.058	278	RC	C1713	CPT				Both			567	255.15	255.15	510.3		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	419.58							Fee Schedule																													510.3							Fee Schedule																																															
SYNTHESE SCREW # 204.818	278	RC	C1713	CPT				Both			73.5	33.08	33.08	66.15		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	54.39							Fee Schedule																													66.15							Fee Schedule																																															
SYNTHESE SCREW # 207.654	278	RC	C1713	CPT				Both			927.15	417.22	417.22	834.44		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	686.09							Fee Schedule																													834.44							Fee Schedule																																															
SYNTHESE SCREW # 208.875	278	RC	C1713	CPT				Both			1081	486.45	486.45	972.9		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	799.94							Fee Schedule																													972.9							Fee Schedule																																															
SYNTHESE SCREW # 212.134	278	RC	C1713	CPT				Both			567	255.15	255.15	510.3		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	419.58							Fee Schedule																													510.3							Fee Schedule																																															
SYNTHESE SCREW # 212.136	278	RC	C1713	CPT				Both			567	255.15	255.15	510.3		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	419.58							Fee Schedule																													510.3							Fee Schedule																																															
SYNTHESE SCREW # 459.38	278	RC	C1713	CPT				Both			757.05	340.67	340.67	681.35		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	560.22							Fee Schedule																													681.35							Fee Schedule																																															
SYNTHESE SCREW # 459.46	278	RC	C1713	CPT				Both			538.65	242.39	242.39	484.79		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	398.6							Fee Schedule																													484.79							Fee Schedule																																															
SYNTHESE SCREW #223.551	278	RC	C1713	CPT				Both			1339	602.55	602.55	1205.1		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	990.86							Fee Schedule																													1205.1							Fee Schedule																																															
SYNTHESE SELF TAPPING K WIRE 292.12	278	RC	C1713	CPT				Both			38	17.1	17.1	34.2		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	28.12							Fee Schedule																													34.2							Fee Schedule																																															
SYNTHESE SELF TAPPING K WIRE 292.16	278	RC	C1713	CPT				Both			40	18	18	36		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	29.6							Fee Schedule																													36							Fee Schedule																																															
SYNTHESE SELF TAPPING K WIRE 292.20	278	RC	C1713	CPT				Both			47	21.15	21.15	42.3		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	34.78							Fee Schedule																													42.3							Fee Schedule																																															
SYNTHESE SELF TAPPING K WIRE 311.34	278	RC	C1713	CPT				Both			53.55	24.1	24.1	48.2		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	39.63							Fee Schedule																													48.2							Fee Schedule																																															
SYNTHESE SELF TAPPING K WIRE 311.46	278	RC	C1713	CPT				Both			53.55	24.1	24.1	48.2		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	39.63							Fee Schedule																													48.2							Fee Schedule																																															
SYNTHESE SELF TAPPING K WIRE 492.16	278	RC	C1713	CPT				Both			33.6	15.12	15.12	30.24		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	24.86							Fee Schedule																													30.24							Fee Schedule																																															
SYNTHESE SELFDRILL 5 OSCHANZ 294.783	278	RC	C1713	CPT				Both			344.4	154.98	154.98	309.96		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	254.86							Fee Schedule																													309.96							Fee Schedule																																															
SYNTHESE SMALL T PLATE 6 HOLE 241.13	278	RC	C1713	CPT				Both			237.3	106.79	106.79	213.57		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	175.6							Fee Schedule																													213.57							Fee Schedule																																															
SYNTHESE SMALL T PLATE 8 HOLE 241.15	278	RC	C1713	CPT				Both			273	122.85	122.85	245.7		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	202.02							Fee Schedule																													245.7							Fee Schedule																																															
SYNTHESE SOFT TISSUE PROTECTOR 4.0	272	RC	C1713	CPT				Both			2756.25	1240.31	306.41	2480.63	306.41							Fee Schedule		2039.63							Fee Schedule																													2480.63							Fee Schedule																																															
SYNTHESE SOLID LOCKING SCREW 222.587	278	RC	C1713	CPT				Both			378	170.1	170.1	340.2		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	279.72							Fee Schedule																													340.2							Fee Schedule																																															
SYNTHESE SOLID LOCKING SCREW 222.589	278	RC	C1713	CPT				Both			378	170.1	170.1	340.2		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	279.72							Fee Schedule																													340.2							Fee Schedule																																															
SYNTHESE SPADE-POINT WIRE 292.40	278	RC	C1713	CPT				Both			244.65	110.09	110.09	220.19		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	181.04							Fee Schedule																													220.19							Fee Schedule																																															
SYNTHESE SPIRAL SCREW #462.644	278	RC	C1713	CPT				Both			1197	538.65	538.65	1077.3		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	885.78							Fee Schedule																													1077.3							Fee Schedule																																															
SYNTHESE SPIRAL SCREW #462.646	278	RC	C1713	CPT				Both			1197	538.65	538.65	1077.3		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	885.78							Fee Schedule																													1077.3							Fee Schedule																																															
SYNTHESE STRGHT. OUTRIG POST 390.012	278	RC	C1713	CPT				Both			435.75	196.09	196.09	392.18		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	322.46							Fee Schedule																													392.18							Fee Schedule																																															
SYNTHESE T PLATE 4 HOLE 241.131	278	RC	C1713	CPT				Both			674.1	303.35	303.35	606.69		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	498.83							Fee Schedule																													606.69							Fee Schedule																																															
SYNTHESE TFN NAIL 12MM 456.322.5	278	RC	C1713	CPT				Both			2958.9	1331.51	1331.51	2663.01		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	2189.59							Fee Schedule																													2663.01							Fee Schedule																																															
SYNTHESE THRD. TIP REDUCTON WIRE#292.600	278	RC	C1713	CPT				Both			1004.85	452.18	452.18	904.37		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	743.59							Fee Schedule																													904.37							Fee Schedule																																															
SYNTHESE TI END CAP SPIR.BLADE#462.665	278	RC	C1713	CPT				Both			374.85	168.68	168.68	337.37		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	277.39							Fee Schedule																													337.37							Fee Schedule																																															
SYNTHESE TI LOCK SCREW 4.0 #458.850S	278	RC	C1713	CPT				Both			459.9	206.96	206.96	413.91		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	340.33							Fee Schedule																													413.91							Fee Schedule																																															
SYNTHESE TI SOLID HUMER.NAIL #462.724S	278	RC	C1713	CPT				Both			4177.95	1880.08	1880.08	3760.16		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	3091.68							Fee Schedule																													3760.16							Fee Schedule																																															
SYNTHESE TI SOLID TIB NAIL 478.335	278	RC	C1713	CPT				Both			2699.55	1214.8	1214.8	2429.6		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1997.67							Fee Schedule																													2429.6							Fee Schedule																																															
SYNTHESE TIBIA PLATE 238.700	278	RC	C1713	CPT				Both			4740.75	2133.34	2133.34	4266.68		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	3508.16							Fee Schedule																													4266.68							Fee Schedule																																															
SYNTHESE TIBIA PLATE 238.701	278	RC	C1713	CPT				Both			4644.15	2089.87	2089.87	4179.74		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	3436.67							Fee Schedule																													4179.74							Fee Schedule																																															
SYNTHESE TIBIA PLATE 238.703	278	RC	C1713	CPT				Both			4695.6	2113.02	2113.02	4226.04		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	3474.74							Fee Schedule																													4226.04							Fee Schedule																																															
SYNTHESE TIBIA PLATE 238.705	278	RC	C1713	CPT				Both			4740.75	2133.34	2133.34	4266.68		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	3508.16							Fee Schedule																													4266.68							Fee Schedule																																															
SYNTHESE TIBIA PLATE 238.708	278	RC	C1713	CPT				Both			5820.15	2619.07	2619.07	5238.14		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	4306.91							Fee Schedule																													5238.14							Fee Schedule																																															
SYNTHESE TIBIA PLATE 238.709	278	RC	C1713	CPT				Both			4842.6	2179.17	2179.17	4358.34		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	3583.52							Fee Schedule																													4358.34							Fee Schedule																																															
SYNTHESE TIBIA PLATE 238.711	278	RC	C1713	CPT				Both			4904.55	2207.05	2207.05	4414.1		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	3629.37							Fee Schedule																													4414.1							Fee Schedule																																															
SYNTHESE TIBIA PLATE 240.036	278	RC	C1713	CPT				Both			4462.5	2008.13	2008.13	4016.25		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	3302.25							Fee Schedule																													4016.25							Fee Schedule																																															
SYNTHESE TIBIA PLATE 240.039	278	RC	C1713	CPT				Both			5608.05	2523.62	2523.62	5047.25		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	4149.96							Fee Schedule																													5047.25							Fee Schedule																																															
SYNTHESE TIBIA PLATE 240.040	278	RC	C1713	CPT				Both			4751.25	2138.06	2138.06	4276.13		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	3515.93							Fee Schedule																													4276.13							Fee Schedule																																															
SYNTHESE TIBIA PLATE 240.041	278	RC	C1713	CPT				Both			5673.15	2552.92	2552.92	5105.84		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	4198.13							Fee Schedule																													5105.84							Fee Schedule																																															
SYNTHESE TIBIA PLATE 240.042	278	RC	C1713	CPT				Both			4621.05	2079.47	2079.47	4158.95		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	3419.58							Fee Schedule																													4158.95							Fee Schedule																																															
SYNTHESE TIBIA PLATE 240.043	278	RC	C1713	CPT				Both			4621.05	2079.47	2079.47	4158.95		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	3419.58							Fee Schedule																													4158.95							Fee Schedule																																															
SYNTHESE TIBIA PLATE 240.044	278	RC	C1713	CPT				Both			4672.5	2102.63	2102.63	4205.25		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	3457.65							Fee Schedule																													4205.25							Fee Schedule																																															
SYNTHESE TIBIA PLATE 240.045	278	RC	C1713	CPT				Both			4672.5	2102.63	2102.63	4205.25		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	3457.65							Fee Schedule																													4205.25							Fee Schedule																																															
SYNTHESE TIBIAL NAIL 479.308	278	RC	C1713	CPT				Both			2531.55	1139.2	1139.2	2278.4		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1873.35							Fee Schedule																													2278.4							Fee Schedule																																															
SYNTHESE TITANIUM BLADE 04.038.270	278	RC	C1713	CPT				Both			2988.3	1344.74	1344.74	2689.47		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	2211.34							Fee Schedule																													2689.47							Fee Schedule																																															
SYNTHESE TITANIUM BLADE 04.038.330	278	RC	C1713	CPT				Both			2988.3	1344.74	1344.74	2689.47		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	2211.34							Fee Schedule																													2689.47							Fee Schedule																																															
SYNTHESE WASHERS 219.98	278	RC	C1713	CPT				Both			115.5	51.98	51.98	103.95		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	85.47							Fee Schedule																													103.95							Fee Schedule																																															
SYNTHESE WASHERS 219.99	278	RC	C1713	CPT				Both			126	56.7	56.7	113.4		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	93.24							Fee Schedule																													113.4							Fee Schedule																																															
SYNTHESE X-FIX CLAMPS 390.052	278	RC	C1713	CPT				Both			5958.75	2681.44	2681.44	5362.88		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	4409.48							Fee Schedule																													5362.88							Fee Schedule																																															
SYNVISC 8 MG/ML- 2ML SYRINGE / 3 PACK	636	RC	J7325	CPT				Both			1306.2	587.79	6.96	1175.58		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	6.96							Fee Schedule		7.79							Fee Schedule																				1175.58							Fee Schedule																																															
SYNVISC-ONE 48MG/6ML	636	RC	J7325	CPT				Both			4701.9	2115.86	6.96	4231.71		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	6.96							Fee Schedule		7.79							Fee Schedule																				4231.71							Fee Schedule																																															
SYRINGE 60 CC	272	RC	A4213	CPT				Both			0.37	0.17	0.17	0.52	0.52							Fee Schedule		0.27							Fee Schedule																													0.33							Fee Schedule																																															
SYRINGE ONLY 1CC LUER LOCK #309628	272	RC						Both			1	0.45	0.45	8.7	0.65							Fee Schedule		0.74							Fee Schedule																				7.56							Fee Schedule		0.9							Fee Schedule		8.7							Fee Schedule		7.03							Fee Schedule											8.7							Fee Schedule		7.03							Fee Schedule		
SYRINGE PUMP PCA SET #2L3508	272	RC						Both			23.1	10.4	7.03	20.79	15.02							Fee Schedule		17.09							Fee Schedule																				7.56							Fee Schedule		20.79							Fee Schedule		8.7							Fee Schedule		7.03							Fee Schedule											8.7							Fee Schedule		7.03							Fee Schedule		
SYS LUPUS (SLE) DIS ACTIVITY PNL 19882	302	RC	86225	CPT				Both			247.25	111.26	12.22	222.53	12.22							Fee Schedule		15.27							Fee Schedule		14.15							Fee Schedule		13.74							Fee Schedule											222.53							Fee Schedule																				13.74							Fee Schedule																				
SYSTANE OPTH SOL	250	RC	A9270	CPT				Both			37.08	16.69	0.01	33.37	0.01							Fee Schedule		27.44							Fee Schedule																													33.37							Fee Schedule																																															
SYTHNES PLATE 239.954	278	RC	C1713	CPT				Both			6318.9	2843.51	2843.51	5687.01		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	4675.99							Fee Schedule																													5687.01							Fee Schedule																																															
T CELLS T4 & T8 RATIO 7924	302	RC	86360	CPT				Both			257.25	115.76	12.78	231.53	41.77							Fee Schedule		52.2							Fee Schedule		48.39							Fee Schedule		46.98							Fee Schedule		13.74							Fee Schedule		231.53							Fee Schedule		15.8							Fee Schedule		12.78							Fee Schedule		46.98							Fee Schedule		15.8							Fee Schedule		12.78							Fee Schedule		
T FIX CANNULA 5MMX55MM	272	RC						Both			44.1	19.85	19.85	39.69	28.67							Fee Schedule		32.63							Fee Schedule																													39.69							Fee Schedule																																															
T FIX CURVED SINGLE	272	RC						Both			169.05	76.07	76.07	152.15	109.88							Fee Schedule		125.1							Fee Schedule																													152.15							Fee Schedule																																															
T FIX STRAIGHT DOUBLE	272	RC						Both			169.05	76.07	43.69	152.15	109.88							Fee Schedule		125.1							Fee Schedule																				46.98							Fee Schedule		152.15							Fee Schedule		54.03							Fee Schedule		43.69							Fee Schedule											54.03							Fee Schedule		43.69							Fee Schedule		
T FIX STRAIGHT SINGLE	272	RC						Both			169.05	76.07	76.07	152.15	109.88							Fee Schedule		125.1							Fee Schedule																													152.15							Fee Schedule																																															
T TUBE GREEN 1077	271	RC						Both			1	0.45	0.45	0.9	0.65							Fee Schedule		0.74							Fee Schedule																													0.9							Fee Schedule																																															
T U R Y SET	272	RC						Both			28.35	12.76	12.76	25.52	18.43							Fee Schedule		20.98							Fee Schedule																													25.52							Fee Schedule																																															
T3 FREE  QUEST 34429	301	RC	84481	CPT				Both			234	105.3	15.06	210.6	15.06							Fee Schedule		18.82							Fee Schedule		17.45							Fee Schedule		16.94							Fee Schedule											210.6							Fee Schedule																				16.94							Fee Schedule																				
T3 REVERSE 90963  1 ML SERUM	301	RC	84482	CPT				Both			89.25	40.16	14.01	80.33	14.01							Fee Schedule		17.51							Fee Schedule		16.23							Fee Schedule		15.76							Fee Schedule											80.33							Fee Schedule																				15.76							Fee Schedule																				
T3 UPTAKE 861	301	RC	84479	CPT				Both			54	24.3	5.75	48.6	5.75							Fee Schedule		7.18							Fee Schedule		6.66							Fee Schedule		6.47							Fee Schedule											48.6							Fee Schedule																				6.47							Fee Schedule																				
T4 FREE DIRECT DIALYSIS 35167 RED TUBE	301	RC	84439	CPT				Both			52.5	23.63	8.01	47.25	8.01							Fee Schedule		10.02							Fee Schedule		9.29							Fee Schedule		9.02							Fee Schedule		16.94							Fee Schedule		47.25							Fee Schedule		19.48							Fee Schedule		15.75							Fee Schedule		9.02							Fee Schedule		19.48							Fee Schedule		15.75							Fee Schedule		
T4 FREE THYROXINE GREEN OR RED	301	RC	84439	CPT				Both			80.85	36.38	8.01	72.77	8.01							Fee Schedule		10.02							Fee Schedule		9.29							Fee Schedule		9.02							Fee Schedule		15.76							Fee Schedule		72.77							Fee Schedule		18.12							Fee Schedule		14.66							Fee Schedule		9.02							Fee Schedule		18.12							Fee Schedule		14.66							Fee Schedule		
TAB-A-VITE (THERA) TABLET	250	RC	A9270	CPT				Both			6.3	2.84	0.01	7.44	0.01							Fee Schedule		4.66							Fee Schedule																				6.47							Fee Schedule		5.67							Fee Schedule		7.44							Fee Schedule		6.02							Fee Schedule											7.44							Fee Schedule		6.02							Fee Schedule		
TABLE COVERS #DYNJP2311	272	RC						Both			4.2	1.89	1.89	10.37	2.73							Fee Schedule		3.11							Fee Schedule																				9.02							Fee Schedule		3.78							Fee Schedule		10.37							Fee Schedule		8.39							Fee Schedule											10.37							Fee Schedule		8.39							Fee Schedule		
TABLE COVERS #DYNJP2312	272	RC						Both			8	3.6	3.6	10.37	5.2							Fee Schedule		5.92							Fee Schedule																				9.02							Fee Schedule		7.2							Fee Schedule		10.37							Fee Schedule		8.39							Fee Schedule											10.37							Fee Schedule		8.39							Fee Schedule		
TACROLIMUS 70007 PROGRAF LAVENDER TUBE	301	RC	80197	CPT				Both			252	113.4	12.21	226.8	12.21							Fee Schedule		15.26							Fee Schedule		14.14							Fee Schedule		13.73							Fee Schedule											226.8							Fee Schedule																				13.73							Fee Schedule																				
TACTRA PENILE PROSETHESIS 11MM 720081-01	278	RC	C2622	CPT				Both			41985	18893.25	18893.25	37786.5		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	31068.9							Fee Schedule																													37786.5							Fee Schedule																																															
TAGAMET 300 MG/50 ML PREMIX	250	RC						Both			17.57	7.91	7.91	15.81	11.42							Fee Schedule		13							Fee Schedule																													15.81							Fee Schedule																																															
TALWIN NX TABLET UD	250	RC	A9270	CPT				Both			4.2	1.89	0.01	15.79	0.01							Fee Schedule		3.11							Fee Schedule																				13.73							Fee Schedule		3.78							Fee Schedule		15.79							Fee Schedule		12.77							Fee Schedule											15.79							Fee Schedule		12.77							Fee Schedule		
TAMIFLU 12 MG/ML ORAL SUSP- 60 ML	250	RC	A9270	CPT				Both			117.6	52.92	0.01	105.84	0.01							Fee Schedule		87.02							Fee Schedule																													105.84							Fee Schedule																																															
TAMOXIFEN 10MG (NOLVADEX) TABLET	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
TAMSULOSIN 0.4MG (FLOMAX) CAPSULE	250	RC	A9270	CPT				Both			13.65	6.14	0.01	12.29	0.01							Fee Schedule		10.1							Fee Schedule																													12.29							Fee Schedule																																															
TAUT INTRODUCER #PI-104	272	RC						Both			89.25	40.16	40.16	80.33	58.01							Fee Schedule		66.05							Fee Schedule																													80.33							Fee Schedule																																															
TAUT INTRODUCER #PI-128	272	RC						Both			185	83.25	83.25	166.5	120.25							Fee Schedule		136.9							Fee Schedule																													166.5							Fee Schedule																																															
TAUT INTRODUCER #PI-93	272	RC						Both			118	53.1	53.1	106.2	76.7							Fee Schedule		87.32							Fee Schedule																													106.2							Fee Schedule																																															
TAVIST 2.68 MG TABLET UD	250	RC	A9270	CPT				Both			4.2	1.89	0.01	3.78	0.01							Fee Schedule		3.11							Fee Schedule																													3.78							Fee Schedule																																															
TAVIST D TABLET UD	250	RC	A9270	CPT				Both			2.5	1.13	0.01	2.25	0.01							Fee Schedule		1.85							Fee Schedule																													2.25							Fee Schedule																																															
TB TINE SKIN TEST	302	RC	86580	CPT				Both			31.5	14.18	5.27	28.35	5.27							Fee Schedule		7.66							Fee Schedule											8.98							Fee Schedule											28.35							Fee Schedule																																															
TCC CASTING BOOT LARGE #TCC21114	274	RC	L4387	CPT				Both			274	123.3	123.3	246.6		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	202.76							Fee Schedule		201.77							Fee Schedule																				246.6							Fee Schedule																																															
TCC CASTING BOOT REG #TCC21100	274	RC	L4387	CPT				Both			274	123.3	123.3	246.6		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	202.76							Fee Schedule		201.77							Fee Schedule																				246.6							Fee Schedule																																															
TCC CASTING BOOT XL #TCC21124	274	RC	L4387	CPT				Both			277	124.65	124.65	249.3		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	204.98							Fee Schedule		201.77							Fee Schedule																				249.3							Fee Schedule																																															
TCC CASTING SYSTEM 3  #TCC23001 INTEGRA	274	RC	Q4038	CPT				Both			312	140.4	54.05	280.8		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	230.88							Fee Schedule		54.05							Fee Schedule											195.89							Fee Schedule		280.8							Fee Schedule		225.27							Fee Schedule		182.18							Fee Schedule											225.27							Fee Schedule		182.18							Fee Schedule		
TCC CASTING SYSTEM 3  #TCC23051	274	RC	Q4038	CPT				Both			379	170.55	54.05	341.1		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	280.46							Fee Schedule		54.05							Fee Schedule											195.89							Fee Schedule		341.1							Fee Schedule		225.27							Fee Schedule		182.18							Fee Schedule											225.27							Fee Schedule		182.18							Fee Schedule		
TCC CASTING SYSTEM 4  #TCC24001	274	RC	Q4038	CPT				Both			327	147.15	54.05	294.3		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	241.98							Fee Schedule		54.05							Fee Schedule											195.89							Fee Schedule		294.3							Fee Schedule		225.27							Fee Schedule		182.18							Fee Schedule											225.27							Fee Schedule		182.18							Fee Schedule		
TCC TRANSMET CASTING BOOT #TCC21131	274	RC	L4387	CPT				Both			343	154.35	48.81	308.7		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	253.82							Fee Schedule		201.77							Fee Schedule											52.48							Fee Schedule		308.7							Fee Schedule		60.35							Fee Schedule		48.81							Fee Schedule											60.35							Fee Schedule		48.81							Fee Schedule		
TEARS PLUS	250	RC	A9270	CPT				Both			20.82	9.37	0.01	60.35	0.01							Fee Schedule		15.41							Fee Schedule																				52.48							Fee Schedule		18.74							Fee Schedule		60.35							Fee Schedule		48.81							Fee Schedule											60.35							Fee Schedule		48.81							Fee Schedule		
TED HOSE KNEE	271	RC						Both			18.9	8.51	8.51	60.35	12.29							Fee Schedule		13.99							Fee Schedule																				52.48							Fee Schedule		17.01							Fee Schedule		60.35							Fee Schedule		48.81							Fee Schedule											60.35							Fee Schedule		48.81							Fee Schedule		
TED HOSE KNEE LARGE #7203	271	RC	A4500	CPT				Both			8.45	3.8	2.59	225.27	2.59							Fee Schedule		6.25							Fee Schedule																				195.89							Fee Schedule		7.61							Fee Schedule		225.27							Fee Schedule		182.18							Fee Schedule											225.27							Fee Schedule		182.18							Fee Schedule		
TED HOSE KNEE MED #7115	270	RC						Both			8.45	3.8	3.8	7.61	5.49							Fee Schedule		6.25							Fee Schedule																													7.61							Fee Schedule																																															
TED HOSE KNEE SM #7071	271	RC	A4500	CPT				Both			8	3.6	2.59	7.2	2.59							Fee Schedule		5.92							Fee Schedule																													7.2							Fee Schedule																																															
TED HOSE KNEE XLG #7604	271	RC	A4500	CPT				Both			8.45	3.8	2.59	7.61	2.59							Fee Schedule		6.25							Fee Schedule																													7.61							Fee Schedule																																															
TED HOSE THIGH	271	RC						Both			33.6	15.12	15.12	30.24	21.84							Fee Schedule		24.86							Fee Schedule																													30.24							Fee Schedule																																															
TED HOSE THIGH LG #3728LF	271	RC	A4495	CPT				Both			17	7.65	3.37	15.3	3.37							Fee Schedule		12.58							Fee Schedule																													15.3							Fee Schedule																																															
TED HOSE THIGH MED #3416LF	271	RC	A4495	CPT				Both			17	7.65	3.37	15.3	3.37							Fee Schedule		12.58							Fee Schedule																													15.3							Fee Schedule																																															
TED HOSE THIGH SM #3130LF	271	RC	A4495	CPT				Both			17	7.65	3.37	15.3	3.37							Fee Schedule		12.58							Fee Schedule																													15.3							Fee Schedule																																															
TED HOSE THIGH XLG #3180LF	271	RC	A4495	CPT				Both			17	7.65	3.37	15.3	3.37							Fee Schedule		12.58							Fee Schedule																													15.3							Fee Schedule																																															
TEFLARO 600 MG VIAL	636	RC	J0712	CPT				Both			763	343.35	4.25	686.7		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	4.25							Fee Schedule		4.37							Fee Schedule																				686.7							Fee Schedule																																															
TEFLARO 600MG IVPB	636	RC	J0712	CPT				Both			763	343.35	4.25	686.7		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	4.25							Fee Schedule		4.37							Fee Schedule																				686.7							Fee Schedule																																															
TEGADERM	272	RC						Both			2.1	0.95	0.95	1.89	1.37							Fee Schedule		1.55							Fee Schedule																													1.89							Fee Schedule																																															
TEGADERM & PAD 3582	272	RC						Both			1.05	0.47	0.47	4.87	0.68							Fee Schedule		0.78							Fee Schedule																				4.24							Fee Schedule		0.95							Fee Schedule		4.87							Fee Schedule		3.94							Fee Schedule											4.87							Fee Schedule		3.94							Fee Schedule		
TEGADERM & PAD 3584	272	RC						Both			2	0.9	0.9	4.87	1.3							Fee Schedule		1.48							Fee Schedule																				4.24							Fee Schedule		1.8							Fee Schedule		4.87							Fee Schedule		3.94							Fee Schedule											4.87							Fee Schedule		3.94							Fee Schedule		
TEGADERM & PAD 3586	272	RC						Both			2	0.9	0.9	1.8	1.3							Fee Schedule		1.48							Fee Schedule																													1.8							Fee Schedule																																															
TEGADERM & PAD 3591	272	RC						Both			8.4	3.78	3.78	7.56	5.46							Fee Schedule		6.22							Fee Schedule																													7.56							Fee Schedule																																															
TEGADERM 3M 1616	272	RC						Both			3	1.35	1.35	2.7	1.95							Fee Schedule		2.22							Fee Schedule																													2.7							Fee Schedule																																															
TEGADERM 3M 3589	272	RC						Both			3	1.35	1.35	2.7	1.95							Fee Schedule		2.22							Fee Schedule																													2.7							Fee Schedule																																															
TEGADERM CHG # 1659 FOR DRESSING CHNG.	272	RC						Both			22.05	9.92	9.92	19.85	14.33							Fee Schedule		16.32							Fee Schedule																													19.85							Fee Schedule																																															
TEGADERM DRESSING 1627 4X10 3M	270	RC						Both			8.4	3.78	3.78	7.56	5.46							Fee Schedule		6.22							Fee Schedule																													7.56							Fee Schedule																																															
TEGADERM LG 4X4.75 #1626W	272	RC	A6257	CPT				Both			2	0.9	0.9	2.25	1.38							Fee Schedule		1.48							Fee Schedule		2.25							Fee Schedule		1.73							Fee Schedule											1.8							Fee Schedule																																															
TEGADERM LG 7CMX8.5CM 1882	272	RC	A6257	CPT				Both			3	1.35	1.35	2.7	1.38							Fee Schedule		2.22							Fee Schedule		2.25							Fee Schedule		1.73							Fee Schedule											2.7							Fee Schedule																																															
TEGADERM SM 2 3/8X2 3/4 #1624W (FLOORS)	270	RC						Both			1	0.45	0.45	0.9	0.65							Fee Schedule		0.74							Fee Schedule																													0.9							Fee Schedule																																															
TEKTURNA 150 MG (ALISKIREN) TABLET	250	RC	A9270	CPT				Both			78.75	35.44	0.01	70.88	0.01							Fee Schedule		58.28							Fee Schedule																				2.18							Fee Schedule		70.88							Fee Schedule		2.51							Fee Schedule		2.03							Fee Schedule											2.51							Fee Schedule		2.03							Fee Schedule		
TELEFLEX LMA  AIRWAY SIZE 3 175030	270	RC						Both			81.9	36.86	2.03	73.71	53.24							Fee Schedule		60.61							Fee Schedule																				2.18							Fee Schedule		73.71							Fee Schedule		2.51							Fee Schedule		2.03							Fee Schedule											2.51							Fee Schedule		2.03							Fee Schedule		
TELEFLEX LMA  AIRWAY SIZE 4 ALBF040SU	270	RC						Both			81.9	36.86	36.86	73.71	53.24							Fee Schedule		60.61							Fee Schedule																													73.71							Fee Schedule																																															
TELEFLEX LMA  AIRWAY SIZE 4 ALBF040SU	270	RC						Both			81.9	36.86	36.86	73.71	53.24							Fee Schedule		60.61							Fee Schedule																													73.71							Fee Schedule																																															
TELEFLEX LMA  AIRWAY SIZE 5 ALBF050SU	270	RC						Both			81.9	36.86	36.86	73.71	53.24							Fee Schedule		60.61							Fee Schedule																													73.71							Fee Schedule																																															
TELEMETRY POUCH KIT 150	271	RC						Both			18.9	8.51	8.51	17.01	12.29							Fee Schedule		13.99							Fee Schedule																													17.01							Fee Schedule																																															
TELEMETRY POUCH KIT 5-P	271	RC						Both			18.9	8.51	8.51	17.01	12.29							Fee Schedule		13.99							Fee Schedule																													17.01							Fee Schedule																																															
TELEPORT MICROCATHETER 220-15-1000U	272	RC	C1887	CPT				Both			1650	742.5	43.86	1485	43.86							Fee Schedule		1221							Fee Schedule																													1485							Fee Schedule																																															
TELEPORT MICROCATHETER 221-15-1000U	272	RC	C1887	CPT				Both			1650	742.5	43.86	1485	43.86							Fee Schedule		1221							Fee Schedule																													1485							Fee Schedule																																															
TELFA 3X4 DRESSING #NON25710 MEDLINE	272	RC	A6251	CPT				Both			1	0.45	0.45	2.93	1.79							Fee Schedule		0.74							Fee Schedule		2.93							Fee Schedule		2.24							Fee Schedule											0.9							Fee Schedule																																															
TELFA 3X8 DRESSING  CONCORDANCE	272	RC	A6252	CPT				Both			1	0.45	0.45	4.78	2.94							Fee Schedule		0.74							Fee Schedule		4.78							Fee Schedule		3.67							Fee Schedule											0.9							Fee Schedule																																															
TELFA DRESSING 3X8	272	RC						Both			1.05	0.47	0.47	0.95	0.68							Fee Schedule		0.78							Fee Schedule																													0.95							Fee Schedule																																															
TELFA PADS 3X4	272	RC						Both			1.05	0.47	0.47	3.27	0.68							Fee Schedule		0.78							Fee Schedule																				2.84							Fee Schedule		0.95							Fee Schedule		3.27							Fee Schedule		2.64							Fee Schedule											3.27							Fee Schedule		2.64							Fee Schedule		
TELFA PADS 8X3	272	RC						Both			1.05	0.47	0.47	5.34	0.68							Fee Schedule		0.78							Fee Schedule																				4.64							Fee Schedule		0.95							Fee Schedule		5.34							Fee Schedule		4.32							Fee Schedule											5.34							Fee Schedule		4.32							Fee Schedule		
TEMAZEPAM  7.5 MG CAPSULE UD	250	RC	A9270	CPT				Both			6.83	3.07	0.01	6.15	0.01							Fee Schedule		5.05							Fee Schedule																													6.15							Fee Schedule																																															
TEMAZEPAM 15 MG (RESTORIL) CAPSULE	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
TEMAZEPAM 30 MG CAPSULE UD	250	RC	A9270	CPT				Both			4.2	1.89	0.01	3.78	0.01							Fee Schedule		3.11							Fee Schedule																													3.78							Fee Schedule																																															
TEMP PROBE COVER DUCK/ BEAR  31424792	270	RC						Both			1	0.45	0.45	0.9	0.65							Fee Schedule		0.74							Fee Schedule																													0.9							Fee Schedule																																															
TEMP. SENSING CATH. TRAY 16FR #A119216M	272	RC						Both			85	38.25	38.25	76.5	55.25							Fee Schedule		62.9							Fee Schedule																													76.5							Fee Schedule																																															
TENDON ANCHORS (8) FOR IMPLANT #2504-1	278	RC	C1713	CPT				Both			2100	945	945	1890		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1554							Fee Schedule																													1890							Fee Schedule																																															
TENDON BONE PATELLAR BONE (HALF SIZE )	278	RC	C1762	CPT				Both			5365.5	2414.48	2414.48	4828.95		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	3970.47							Fee Schedule																													4828.95							Fee Schedule																																															
TENDON PATELLAR LIGAMENT 04800003	278	RC	C1762	CPT				Both			8913	4010.85	4010.85	8021.7		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	6595.62							Fee Schedule																													8021.7							Fee Schedule																																															
TENDON PERONEUS LONGUS 09600003 (DCIDS)	278	RC	C1762	CPT				Both			3945	1775.25	1775.25	3550.5		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	2919.3							Fee Schedule																													3550.5							Fee Schedule																																															
TENDON TIBIAL ANTERIOR BONE TO BONE	278	RC	C1762	CPT				Both			4877.25	2194.76	2194.76	4389.53		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	3609.17							Fee Schedule																													4389.53							Fee Schedule																																															
TENDON TIBIALIS ANTERIO ( DCI DON.SERV )	278	RC	C1762	CPT				Both			3831	1723.95	1723.95	3447.9		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	2834.94							Fee Schedule																													3447.9							Fee Schedule																																															
TENDON TIBIALIS ANTERIO STRYKER ORTHO	278	RC	C1762	CPT				Both			3727.5	1677.38	1677.38	3354.75		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	2758.35							Fee Schedule																													3354.75							Fee Schedule																																															
TENDON TIBIALIS POSTERIOR # 07804303	278	RC	C1762	CPT				Both			2908.5	1308.83	1308.83	2617.65		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	2152.29							Fee Schedule																													2617.65							Fee Schedule																																															
TENDON TIIALIS ANTERIOR 07804219 (DCIDS)	278	RC	C1762	CPT				Both			4022.55	1810.15	1810.15	3620.3		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	2976.69							Fee Schedule																													3620.3							Fee Schedule																																															
TENDON/ LIGAMENT PATELLAR 40MM RANGE	278	RC	C1762	CPT				Both			6631.8	2984.31	2984.31	5968.62		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	4907.53							Fee Schedule																													5968.62							Fee Schedule																																															
OTHER O.R. PROCEDURES FOR INJURIES WITH CC					908	DRG		Inpatient			44481.14	20016.51	20016.51	20016.51							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period	
OTHER O.R. PROCEDURES FOR INJURIES WITHOUT CC/MCC					909	DRG		Inpatient			47439.05	21347.57	21347.57	21347.57							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period	
TENNIS ELBOW STRAP  ( DJ ORTHO. )	274	RC	L3710	CPT				Both			5.25	2.36	2.36	167.95		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	3.89							Fee Schedule		167.95							Fee Schedule		122.46							Fee Schedule											4.73							Fee Schedule																																															
TENORETIC 50 MG TABLET UD	250	RC	A9270	CPT				Both			2.12	0.95	0.01	1.91	0.01							Fee Schedule		1.57							Fee Schedule																													1.91							Fee Schedule																																															
TENS UNIT LEADS	270	RC						Both			34.65	15.59	15.59	31.19	22.52							Fee Schedule		25.64							Fee Schedule																													31.19							Fee Schedule																																															
TENS UNIT LEADS	270	RC						Both			34.65	15.59	15.59	187.52	22.52							Fee Schedule		25.64							Fee Schedule																				163.06							Fee Schedule		31.19							Fee Schedule		187.52							Fee Schedule		151.65							Fee Schedule											187.52							Fee Schedule		151.65							Fee Schedule		
TENSILON 10MG 1CC	250	RC						Both			12.6	5.67	5.67	11.34	8.19							Fee Schedule		9.32							Fee Schedule																													11.34							Fee Schedule																																															
TENSOPLAST BANDAGE 3   02595002	623	RC	A6451	CPT				Both			10.5	4.73	1.58	9.45	1.58							Fee Schedule		7.77							Fee Schedule		2.58							Fee Schedule																				9.45							Fee Schedule																																															
TEQUIN 400 MG TABLETS	250	RC	A9270	CPT				Both			24.54	11.04	0.01	22.09	0.01							Fee Schedule		18.16							Fee Schedule																													22.09							Fee Schedule																																															
TEQUIN 400 MG/200 ML PREMIX	250	RC						Both			124.83	56.17	56.17	112.35	81.14							Fee Schedule		92.37							Fee Schedule																													112.35							Fee Schedule																																															
TERAZOL 7 VAG CREAM	250	RC	A9270	CPT				Both			70.35	31.66	0.01	63.32	0.01							Fee Schedule		52.06							Fee Schedule																				2.5							Fee Schedule		63.32							Fee Schedule		2.88							Fee Schedule		2.33							Fee Schedule											2.88							Fee Schedule		2.33							Fee Schedule		
TERAZOL-3 VAGINAL CREAM- 20 GM	250	RC	A9270	CPT				Both			129.15	58.12	0.01	116.24	0.01							Fee Schedule		95.57							Fee Schedule																													116.24							Fee Schedule																																															
TERAZOSIN 1MG (HYTRIN) CAPSULE	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
TERAZOSIN 2 MG CAPSULE UD	250	RC	A9270	CPT				Both			4.41	1.98	0.01	3.97	0.01							Fee Schedule		3.26							Fee Schedule																													3.97							Fee Schedule																																															
TERAZOSIN 5MG (HYTRIN) CAPSULE	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
TERBUTALINE 1 MG/ML INJECTION	636	RC	J3105	CPT				Both			14.7	6.62	2.9	13.23		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	10.88							Fee Schedule		2.9							Fee Schedule		3.2							Fee Schedule											13.23							Fee Schedule																																															
TERBUTALINE 2.5MG (BRETHINE) TABLET	250	RC	A9270	CPT				Both			16.8	7.56	0.01	15.12	0.01							Fee Schedule		12.43							Fee Schedule																													15.12							Fee Schedule																																															
TERBUTALINE 5MG (BRETHINE) TABLET	250	RC	A9270	CPT				Both			21	9.45	0.01	18.9	0.01							Fee Schedule		15.54							Fee Schedule																													18.9							Fee Schedule																																															
TERUMO ASPIRATION CATHETER 30-6100	272	RC	C1725	CPT				Both			1682.1	756.95	2.62	1513.89	93.3							Fee Schedule		1244.75							Fee Schedule																				2.82							Fee Schedule		1513.89							Fee Schedule		3.24							Fee Schedule		2.62							Fee Schedule											3.24							Fee Schedule		2.62							Fee Schedule		
TERUMO ASPIRATION CATHETER 30-7100	272	RC	C1725	CPT				Both			1682.1	756.95	93.3	1513.89	93.3							Fee Schedule		1244.75							Fee Schedule																													1513.89							Fee Schedule																																															
TERUMO CATHETER CG412	272	RC	C1725	CPT				Both			288	129.6	93.3	259.2	93.3							Fee Schedule		213.12							Fee Schedule																													259.2							Fee Schedule																																															
TERUMO CATHETER CG413	272	RC	C1725	CPT				Both			260.4	117.18	93.3	234.36	93.3							Fee Schedule		192.7							Fee Schedule																													234.36							Fee Schedule																																															
TERUMO CATHETER CG415	272	RC	C1725	CPT				Both			267	120.15	93.3	240.3	93.3							Fee Schedule		197.58							Fee Schedule																													240.3							Fee Schedule																																															
TERUMO CATHETER CG416	272	RC	C1725	CPT				Both			220.5	99.23	93.3	198.45	93.3							Fee Schedule		163.17							Fee Schedule																													198.45							Fee Schedule																																															
TERUMO CATHETER CG507	272	RC	C1725	CPT				Both			288	129.6	93.3	259.2	93.3							Fee Schedule		213.12							Fee Schedule																													259.2							Fee Schedule																																															
TERUMO CATHETER CG508	272	RC	C1725	CPT				Both			268	120.6	93.3	241.2	93.3							Fee Schedule		198.32							Fee Schedule																													241.2							Fee Schedule																																															
TERUMO CATHETER CG509	272	RC	C1725	CPT				Both			260.4	117.18	93.3	234.36	93.3							Fee Schedule		192.7							Fee Schedule																													234.36							Fee Schedule																																															
TERUMO DESTINATION SHEATHS 54-74501	272	RC	C1894	CPT				Both			474.08	213.34	87.34	426.67	87.34							Fee Schedule		350.82							Fee Schedule																													426.67							Fee Schedule																																															
TERUMO DESTINATION SHEATHS RSC02	272	RC	C1894	CPT				Both			519.75	233.89	87.34	467.78	87.34							Fee Schedule		384.62							Fee Schedule																													467.78							Fee Schedule																																															
TERUMO DESTINATION SHEATHS RSC05	272	RC	C1894	CPT				Both			519.75	233.89	87.34	467.78	87.34							Fee Schedule		384.62							Fee Schedule																													467.78							Fee Schedule																																															
TERUMO DESTINATION SHEATHS RSC06	272	RC	C1894	CPT				Both			519.75	233.89	87.34	467.78	87.34							Fee Schedule		384.62							Fee Schedule																													467.78							Fee Schedule																																															
TERUMO DESTINATION SHEATHS RSP02	272	RC	C1894	CPT				Both			467.25	210.26	87.34	420.53	87.34							Fee Schedule		345.77							Fee Schedule																													420.53							Fee Schedule																																															
TERUMO FINECROSS CATHETER 35-1450	272	RC	C1725	CPT				Both			1890	850.5	93.3	1701	93.3							Fee Schedule		1398.6							Fee Schedule																													1701							Fee Schedule																																															
TERUMO GLIDE CATH SLENDER 80-1060	272	RC	C1894	CPT				Both			232.05	104.42	87.34	208.85	87.34							Fee Schedule		171.72							Fee Schedule																													208.85							Fee Schedule																																															
TERUMO GLIDECATH 5FR STRAIGHT TAPE CG506	272	RC	C1725	CPT				Both			267	120.15	93.3	240.3	93.3							Fee Schedule		197.58							Fee Schedule																													240.3							Fee Schedule																																															
TERUMO GUIDE CATH. # RSR13	270	RC	C1887	CPT				Both			435.75	196.09	43.86	392.18	43.86							Fee Schedule		322.46							Fee Schedule																													392.18							Fee Schedule																																															
TERUMO GUIDE CATH. # RSR14	270	RC	C1887	CPT				Both			435.75	196.09	43.86	392.18	43.86							Fee Schedule		322.46							Fee Schedule																													392.18							Fee Schedule																																															
TERUMO GUIDEWIRE ANGLED  NC35651	272	RC						Both			837	376.65	376.65	753.3	544.05							Fee Schedule		619.38							Fee Schedule																													753.3							Fee Schedule																																															
TERUMO GUIDEWIRE GA3501	272	RC	C1769	CPT				Both			679.35	305.71	154.26	611.42	154.26							Fee Schedule		502.72							Fee Schedule																													611.42							Fee Schedule																																															
TERUMO GUIDEWIRE GA3502	272	RC	C1769	CPT				Both			900	405	154.26	810	154.26							Fee Schedule		666							Fee Schedule																													810							Fee Schedule																																															
TERUMO GUIDEWIRE GR3503	272	RC	C1769	CPT				Both			237	106.65	106.65	213.3	154.26							Fee Schedule		175.38							Fee Schedule																													213.3							Fee Schedule																																															
TERUMO GUIDEWIRE GR3504	272	RC	C1769	CPT				Both			246	110.7	110.7	221.4	154.26							Fee Schedule		182.04							Fee Schedule																													221.4							Fee Schedule																																															
TERUMO GUIDEWIRE GR3506	272	RC	C1769	CPT				Both			177	79.65	79.65	159.3	154.26							Fee Schedule		130.98							Fee Schedule																													159.3							Fee Schedule																																															
TERUMO GUIDEWIRE GR3508	272	RC	C1769	CPT				Both			181.65	81.74	81.74	163.49	154.26							Fee Schedule		134.42							Fee Schedule																													163.49							Fee Schedule																																															
TERUMO GUIDEWIRE GR3509	272	RC	C1769	CPT				Both			0.17	0.08	0.08	154.26	154.26							Fee Schedule		0.13							Fee Schedule																													0.15							Fee Schedule																																															
TERUMO GUIDEWIRE GS3503	272	RC	C1769	CPT				Both			215.25	96.86	96.86	193.73	154.26							Fee Schedule		159.29							Fee Schedule																													193.73							Fee Schedule																																															
TERUMO GUIDEWIRE GS3504	272	RC	C1769	CPT				Both			228.9	103.01	103.01	206.01	154.26							Fee Schedule		169.39							Fee Schedule																													206.01							Fee Schedule																																															
TERUMO GUIDEWIRE GS3508	272	RC	C1769	CPT				Both			215.25	96.86	96.86	193.73	154.26							Fee Schedule		159.29							Fee Schedule																													193.73							Fee Schedule																																															
TERUMO GUIDEWIRE GS3509	272	RC	C1769	CPT				Both			300	135	135	270	154.26							Fee Schedule		222							Fee Schedule																													270							Fee Schedule																																															
TERUMO GUIDEWIRE STRAIGHT  NC35650	272	RC						Both			837	376.65	376.65	753.3	544.05							Fee Schedule		619.38							Fee Schedule																													753.3							Fee Schedule																																															
TERUMO GUIDEWIRE TD01	272	RC	C1769	CPT				Both			21	9.45	9.45	154.26	154.26							Fee Schedule		15.54							Fee Schedule																													18.9							Fee Schedule																																															
TERUMO GUIDING SHEATH 54-64501	272	RC						Both			441	198.45	198.45	396.9	286.65							Fee Schedule		326.34							Fee Schedule																													396.9							Fee Schedule																																															
TERUMO GUIDING SHEATH RSP01	272	RC						Both			477.75	214.99	214.99	429.98	310.54							Fee Schedule		353.54							Fee Schedule																													429.98							Fee Schedule																																															
TERUMO INSUFLATOR ATRION QL2530 #96358	272	RC						Both			157.5	70.88	70.88	141.75	102.38							Fee Schedule		116.55							Fee Schedule																													141.75							Fee Schedule																																															
TERUMO INTRODUCER SHEATHS RSB503	272	RC	C1894	CPT				Both			122.85	55.28	55.28	110.57	87.34							Fee Schedule		90.91							Fee Schedule																													110.57							Fee Schedule																																															
TERUMO INTRODUCER SHEATHS RSB512	272	RC	C1894	CPT				Both			102.9	46.31	46.31	92.61	87.34							Fee Schedule		76.15							Fee Schedule																													92.61							Fee Schedule																																															
TERUMO INTRODUCER SHEATHS RSB603	272	RC	C1894	CPT				Both			122.85	55.28	55.28	110.57	87.34							Fee Schedule		90.91							Fee Schedule																													110.57							Fee Schedule																																															
TERUMO INTRODUCER SHEATHS RSB612	272	RC	C1894	CPT				Both			102.9	46.31	46.31	92.61	87.34							Fee Schedule		76.15							Fee Schedule																													92.61							Fee Schedule																																															
TERUMO INTRODUCER SHEATHS RSS004	272	RC	C1894	CPT				Both			55.65	25.04	25.04	87.34	87.34							Fee Schedule		41.18							Fee Schedule																													50.09							Fee Schedule																																															
TERUMO INTRODUCER SHEATHS RSS104	272	RC	C1894	CPT				Both			58.8	26.46	26.46	87.34	87.34							Fee Schedule		43.51							Fee Schedule																													52.92							Fee Schedule																																															
TERUMO INTRODUCER SHEATHS RSS402	272	RC	C1894	CPT				Both			57.75	25.99	25.99	87.34	87.34							Fee Schedule		42.74							Fee Schedule																													51.98							Fee Schedule																																															
TERUMO INTRODUCER SHEATHS RSS502	272	RC	C1894	CPT				Both			58.8	26.46	26.46	87.34	87.34							Fee Schedule		43.51							Fee Schedule																													52.92							Fee Schedule																																															
TERUMO INTRODUCER SHEATHS RSS602	272	RC	C1894	CPT				Both			65	29.25	29.25	87.34	87.34							Fee Schedule		48.1							Fee Schedule																													58.5							Fee Schedule																																															
TERUMO INTRODUCER SHEATHS RSS702	272	RC	C1894	CPT				Both			69	31.05	31.05	87.34	87.34							Fee Schedule		51.06							Fee Schedule																													62.1							Fee Schedule																																															
TERUMO INTRODUCER SHEATHS RSS802	272	RC	C1894	CPT				Both			57.75	25.99	25.99	87.34	87.34							Fee Schedule		42.74							Fee Schedule																													51.98							Fee Schedule																																															
TERUMO INTRODUCER SHEATHS RSS902	272	RC	C1894	CPT				Both			57.75	25.99	25.99	87.34	87.34							Fee Schedule		42.74							Fee Schedule																													51.98							Fee Schedule																																															
TERUMO J WIRE 97000205	272	RC	C1769	CPT				Both			34.65	15.59	15.59	154.26	154.26							Fee Schedule		25.64							Fee Schedule																													31.19							Fee Schedule																																															
TERUMO NAVICROSS CATH  NC35130	272	RC	C1887	CPT				Both			837	376.65	43.86	753.3	43.86							Fee Schedule		619.38							Fee Schedule																													753.3							Fee Schedule																																															
TERUMO OBTURATOR SHEATHS XX501	272	RC	C1894	CPT				Both			21	9.45	9.45	87.34	87.34							Fee Schedule		15.54							Fee Schedule																													18.9							Fee Schedule																																															
TERUMO OBTURATOR SHEATHS XX601	272	RC	C1894	CPT				Both			21	9.45	9.45	87.34	87.34							Fee Schedule		15.54							Fee Schedule																													18.9							Fee Schedule																																															
TERUMO OBTURATOR SHEATHS XX701	272	RC	C1894	CPT				Both			21	9.45	9.45	87.34	87.34							Fee Schedule		15.54							Fee Schedule																													18.9							Fee Schedule																																															
TERUMO PINNACLE DESTINATION 54-54504	272	RC						Both			441	198.45	198.45	396.9	286.65							Fee Schedule		326.34							Fee Schedule																													396.9							Fee Schedule																																															
TERUMO PRECISION ACCESS KIT 70-4160	272	RC						Both			211.05	94.97	94.97	189.95	137.18							Fee Schedule		156.18							Fee Schedule																													189.95							Fee Schedule																																															
TERUMO PRECISION ACCESS KIT 70-5160	272	RC						Both			211.05	94.97	94.97	189.95	137.18							Fee Schedule		156.18							Fee Schedule																													189.95							Fee Schedule																																															
TERUMO RADIAL ACCESS SHEATHS RM*RS6F10PA	272	RC	C1894	CPT				Both			220.5	99.23	87.34	198.45	87.34							Fee Schedule		163.17							Fee Schedule																													198.45							Fee Schedule																																															
TERUMO RUNTHROUGH WIRE 25-1013	272	RC	C1769	CPT				Both			455.7	205.07	154.26	410.13	154.26							Fee Schedule		337.22							Fee Schedule																													410.13							Fee Schedule																																															
TERUMO SHEATHS STFI-1425	272	RC	C1894	CPT				Both			2126.25	956.81	87.34	1913.63	87.34							Fee Schedule		1573.43							Fee Schedule																													1913.63							Fee Schedule																																															
TERUMO SUPPORT CATHETER NC35130	272	RC	C1887	CPT				Both			837	376.65	43.86	753.3	43.86							Fee Schedule		619.38							Fee Schedule																													753.3							Fee Schedule																																															
TERUMO SUPPORT CATHETER NC35131	272	RC	C1725	CPT				Both			837	376.65	93.3	753.3	93.3							Fee Schedule		619.38							Fee Schedule																													753.3							Fee Schedule																																															
TEST CULTURE SPUTUM	306	RC	87070	CPT				Both			71.4	32.13	7.66	64.26	7.66							Fee Schedule		9.57							Fee Schedule		8.88							Fee Schedule		8.62							Fee Schedule											64.26							Fee Schedule																				8.62							Fee Schedule																				
ALLERGIC REACTIONS WITHOUT MCC					916	DRG		Inpatient			19258.36	8666.26	8666.26	8666.26							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period	
TESTOPEL PELLETS SUBCUTANEOUS IMPLANT 75	636	RC	J1073	CPT				Both			389.46	175.26	76.64	350.51		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	105.13							Fee Schedule		76.64							Fee Schedule																				350.51							Fee Schedule																																															
TESTOSTER 24HR UR 874 5ML URINE FROZEN	301	RC	84403	CPT				Both			269.85	121.43	8.02	242.87	22.95							Fee Schedule		28.68							Fee Schedule		26.58							Fee Schedule		25.81							Fee Schedule		8.62							Fee Schedule		242.87							Fee Schedule		9.91							Fee Schedule		8.02							Fee Schedule		25.81							Fee Schedule		9.91							Fee Schedule		8.02							Fee Schedule		
TESTOSTERONE TOTAL	301	RC	84403	CPT				Both			145.95	65.68	22.95	131.36	22.95							Fee Schedule		28.68							Fee Schedule		26.58							Fee Schedule		25.81							Fee Schedule											131.36							Fee Schedule																				25.81							Fee Schedule																				
TESTOSTERONE TRANSDERMAL 5 MG/DAY PATCH	250	RC	A9270	CPT				Both			27.3	12.29	0.01	85.56	0.01							Fee Schedule		20.2							Fee Schedule																				74.4							Fee Schedule		24.57							Fee Schedule		85.56							Fee Schedule		69.2							Fee Schedule											85.56							Fee Schedule		69.2							Fee Schedule		
"TESTOSTERONE, FR,BIO,TOT 14966"	301	RC	84403	CPT				Both			145.95	65.68	22.95	131.36	22.95							Fee Schedule		28.68							Fee Schedule		26.58							Fee Schedule		25.81							Fee Schedule		25.81							Fee Schedule		131.36							Fee Schedule		29.68							Fee Schedule		24							Fee Schedule		25.81							Fee Schedule		29.68							Fee Schedule		24							Fee Schedule		
TETANUS ANTIBODIES IGG  4862  SERUM 1ML	302	RC	86774	CPT				Both			159.6	71.82	13.15	143.64	13.15							Fee Schedule		16.44							Fee Schedule		15.24							Fee Schedule		14.8							Fee Schedule		25.81							Fee Schedule		143.64							Fee Schedule		29.68							Fee Schedule		24							Fee Schedule		14.8							Fee Schedule		29.68							Fee Schedule		24							Fee Schedule		
TETANUS IMMUNE GLOBULIN 250 UNIT/SYR	636	RC	J1670	CPT				Both			215.25	96.86	33.74	606.2		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	558.12							Fee Schedule		606.2							Fee Schedule		33.74							Fee Schedule											193.73							Fee Schedule																																															
TETANUS/DIPTHERIA (<6YO OF AGE) VACCINE	636	RC	90702	CPT				Both			63	28.35	24	56.7		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	46.62							Fee Schedule																				25.81							Fee Schedule		56.7							Fee Schedule		29.68							Fee Schedule		24							Fee Schedule											29.68							Fee Schedule		24							Fee Schedule		
TETANUS/DIPTHERIA (7YO-ADULT) VACCINE	636	RC	90714	CPT				Both			46.2	20.79	13.76	41.88		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	34.19							Fee Schedule		41.88							Fee Schedule		24.14							Fee Schedule		14.8							Fee Schedule		41.58							Fee Schedule		17.02							Fee Schedule		13.76							Fee Schedule											17.02							Fee Schedule		13.76							Fee Schedule		
TETRACAINE 0.5% OPTH SOL-5ML	250	RC	A9270	CPT				Both			16.8	7.56	0.01	676.82	0.01							Fee Schedule		12.43							Fee Schedule																				588.54							Fee Schedule		15.12							Fee Schedule		676.82							Fee Schedule		547.34							Fee Schedule											676.82							Fee Schedule		547.34							Fee Schedule		
TETRACAINE 0.5% OPTHL SOLN-5ML	250	RC	A9270	CPT				Both			108	48.6	0.01	97.2	0.01							Fee Schedule		79.92							Fee Schedule																													97.2							Fee Schedule																																															
TETRACYCLINE 250 MG CAP	250	RC	A9270	CPT				Both			5.25	2.36	0.01	46.76	0.01							Fee Schedule		3.89							Fee Schedule																				40.66							Fee Schedule		4.73							Fee Schedule		46.76							Fee Schedule		37.82							Fee Schedule											46.76							Fee Schedule		37.82							Fee Schedule		
TETRACYCLINE 250 MG CAPSULE	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
TETRAHYDROZOLINE 0.05% OPTH SOLUTION	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
TEXAS CATH. MEDIUM LATEX FREE #97529	272	RC	A4349	CPT				Both			3	1.35	1.35	2.96	1.82							Fee Schedule		2.22							Fee Schedule		2.96							Fee Schedule																				2.7							Fee Schedule																																															
TEXAS CATH. SMALL #9206	272	RC	A4349	CPT				Both			4	1.8	1.8	3.6	1.82							Fee Schedule		2.96							Fee Schedule		2.96							Fee Schedule																				3.6							Fee Schedule																																															
TEXAS CATHETER	271	RC						Both			5.25	2.36	2.36	4.73	3.41							Fee Schedule		3.89							Fee Schedule																													4.73							Fee Schedule																																															
TEXAS CATHETER MED. EXTENDED WEAR	272	RC	A4349	CPT				Both			3.15	1.42	1.42	3.3	1.82							Fee Schedule		2.33							Fee Schedule		2.96							Fee Schedule											2.87							Fee Schedule		2.84							Fee Schedule		3.3							Fee Schedule		2.67							Fee Schedule											3.3							Fee Schedule		2.67							Fee Schedule		
THEO DUR SPRINKLES:500 MG	250	RC	A9270	CPT				Both			1.58	0.71	0.01	3.3	0.01							Fee Schedule		1.17							Fee Schedule																				2.87							Fee Schedule		1.42							Fee Schedule		3.3							Fee Schedule		2.67							Fee Schedule											3.3							Fee Schedule		2.67							Fee Schedule		
THEO-24 200 MG CAP	250	RC	A9270	CPT				Both			1.58	0.71	0.01	1.42	0.01							Fee Schedule		1.17							Fee Schedule																													1.42							Fee Schedule																																															
THEO-24 200 MG CAPSULE UD	250	RC	A9270	CPT				Both			4.2	1.89	0.01	3.78	0.01							Fee Schedule		3.11							Fee Schedule																				2.87							Fee Schedule		3.78							Fee Schedule		3.3							Fee Schedule		2.67							Fee Schedule											3.3							Fee Schedule		2.67							Fee Schedule		
THEO-24 24HR CAP 100MG EXTENDED RELEASE	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
THEO-24 300 MG CAP	250	RC	A9270	CPT				Both			1.58	0.71	0.01	1.42	0.01							Fee Schedule		1.17							Fee Schedule																													1.42							Fee Schedule																																															
THEO-24 300 MG CAPSULE UD	250	RC	A9270	CPT				Both			4.2	1.89	0.01	3.78	0.01							Fee Schedule		3.11							Fee Schedule																													3.78							Fee Schedule																																															
THEOPHYLLINE	301	RC	80198	CPT				Both			119.7	53.87	12.57	107.73	12.57							Fee Schedule		15.71							Fee Schedule		14.56							Fee Schedule		14.14							Fee Schedule											107.73							Fee Schedule																				14.14							Fee Schedule																				
THEOPHYLLINE  400 MG/D5W 250 ML	636	RC	J0280	CPT				Both			33.6	15.12	1.42	30.24		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	24.86							Fee Schedule		11.49							Fee Schedule		1.42							Fee Schedule											30.24							Fee Schedule																																															
THEOPHYLLINE 100 MG TABLET UD	250	RC	A9270	CPT				Both			4.2	1.89	0.01	3.78	0.01							Fee Schedule		3.11							Fee Schedule																													3.78							Fee Schedule																																															
THEOPHYLLINE 24 HR CAP ER 200MG CAP	250	RC	A9270	CPT				Both			14.7	6.62	0.01	16.26	0.01							Fee Schedule		10.88							Fee Schedule																				14.14							Fee Schedule		13.23							Fee Schedule		16.26							Fee Schedule		13.15							Fee Schedule											16.26							Fee Schedule		13.15							Fee Schedule		
THEOPHYLLINE 300 MG ER TABLET	250	RC	A9270	CPT				Both			6.3	2.84	0.01	12.83	0.01							Fee Schedule		4.66							Fee Schedule																				11.16							Fee Schedule		5.67							Fee Schedule		12.83							Fee Schedule		10.38							Fee Schedule											12.83							Fee Schedule		10.38							Fee Schedule		
THEOPHYLLINE 80MG/15ML ORAL SOLN UD	250	RC	A9270	CPT				Both			3.15	1.42	0.01	2.84	0.01							Fee Schedule		2.33							Fee Schedule																													2.84							Fee Schedule																																															
THEOPHYLLINE PREMIX	258	RC						Both			26.25	11.81	11.81	23.63	17.06							Fee Schedule		19.43							Fee Schedule																													23.63							Fee Schedule																																															
THERA BALL RED 527802	270	RC						Both			17	7.65	7.65	15.3	11.05							Fee Schedule		12.58							Fee Schedule																													15.3							Fee Schedule																																															
THERA BALL YELLOW 527801	270	RC						Both			17	7.65	7.65	15.3	11.05							Fee Schedule		12.58							Fee Schedule																													15.3							Fee Schedule																																															
THERA TUBING BLUE 71610425	270	RC						Both			41	18.45	18.45	36.9	26.65							Fee Schedule		30.34							Fee Schedule																													36.9							Fee Schedule																																															
THERABALL	271	RC						Both			25.2	11.34	11.34	22.68	16.38							Fee Schedule		18.65							Fee Schedule																													22.68							Fee Schedule																																															
THERABAND BLACK 92717904	271	RC						Both			6	2.7	2.7	5.4	3.9							Fee Schedule		4.44							Fee Schedule																													5.4							Fee Schedule																																															
THERABAND BLUE  081234772	271	RC						Both			5	2.25	2.25	4.5	3.25							Fee Schedule		3.7							Fee Schedule																													4.5							Fee Schedule																																															
THERABAND BLUE 92717903	271	RC						Both			5	2.25	2.25	4.5	3.25							Fee Schedule		3.7							Fee Schedule																													4.5							Fee Schedule																																															
THERABAND GREEN  081234764	271	RC						Both			5	2.25	2.25	4.5	3.25							Fee Schedule		3.7							Fee Schedule																													4.5							Fee Schedule																																															
THERABAND GREEN 92717902	271	RC						Both			5	2.25	2.25	4.5	3.25							Fee Schedule		3.7							Fee Schedule																													4.5							Fee Schedule																																															
THERABAND RED  081234756	271	RC						Both			4	1.8	1.8	3.6	2.6							Fee Schedule		2.96							Fee Schedule																													3.6							Fee Schedule																																															
THERABAND RESISTANCE TUBING BLUE 716104	270	RC						Both			5	2.25	2.25	4.5	3.25							Fee Schedule		3.7							Fee Schedule																													4.5							Fee Schedule																																															
THERABAND YELLOW 92717900	271	RC						Both			4	1.8	1.8	3.6	2.6							Fee Schedule		2.96							Fee Schedule																													3.6							Fee Schedule																																															
THERA-CANE	271	RC						Both			87.15	39.22	39.22	78.44	56.65							Fee Schedule		64.49							Fee Schedule																													78.44							Fee Schedule																																															
THERAGRAN LIQ: (EACH)	250	RC	A9270	CPT				Both			15.75	7.09	0.01	14.18	0.01							Fee Schedule		11.66							Fee Schedule																													14.18							Fee Schedule																																															
THERAGRAN M	250	RC	A9270	CPT				Both			1.58	0.71	0.01	1.42	0.01							Fee Schedule		1.17							Fee Schedule																													1.42							Fee Schedule																																															
THERAHONEY GEL 1.5OZ #MNK0015	272	RC	A4649	CPT				Both			30	13.5	13.5	27	19.5							Fee Schedule		22.2							Fee Schedule																													27							Fee Schedule																																															
THERAPEUTIC MULT MIN	250	RC	A9270	CPT				Both			1.58	0.71	0.01	1.42	0.01							Fee Schedule		1.17							Fee Schedule																													1.42							Fee Schedule																																															
THERAPY INFUSION-INS USE OBSER	260	RC						Both			114.45	51.5	51.5	103.01	74.39							Fee Schedule		84.69							Fee Schedule																													103.01							Fee Schedule																																															
THERASKIN 1  X 2  101TSS	636	RC	Q4121	CPT				Both			3109.05	1399.07	130.95	2798.15		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	2300.7							Fee Schedule		130.95							Fee Schedule																				2798.15							Fee Schedule																																															
THERASKIN 39CM  102TSL	636	RC	Q4121	CPT				Both			103.01	46.35	46.35	130.95		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	76.23							Fee Schedule		130.95							Fee Schedule																				92.71							Fee Schedule																																															
THERM.CHOICE BALLOON THERAPY3(J&J)#TC003	272	RC						Both			4315.5	1941.98	1941.98	3883.95	2805.08							Fee Schedule		3193.47							Fee Schedule																													3883.95							Fee Schedule																																															
THERMA CHOICE UTERINE BALLOON #01105	272	RC	C1886	CPT				Both			1606.5	722.93	118.24	1445.85	1101.74							Fee Schedule		1188.81							Fee Schedule																				127.14							Fee Schedule		1445.85							Fee Schedule		146.21							Fee Schedule		118.24							Fee Schedule											146.21							Fee Schedule		118.24							Fee Schedule		
THERMOCHOICE DISP. HEAT PACKS FOR BACK	270	RC						Both			12	5.4	5.4	146.21	7.8							Fee Schedule		8.88							Fee Schedule																				127.14							Fee Schedule		10.8							Fee Schedule		146.21							Fee Schedule		118.24							Fee Schedule											146.21							Fee Schedule		118.24							Fee Schedule		
THERMOCHOICE DISP. HEAT PACKS FOR NECK	270	RC						Both			23.1	10.4	10.4	20.79	15.02							Fee Schedule		17.09							Fee Schedule																													20.79							Fee Schedule																																															
THERMOMETER GLASS ORAL #20010	270	RC						Both			1.05	0.47	0.47	0.95	0.68							Fee Schedule		0.78							Fee Schedule																													0.95							Fee Schedule																																															
THIAMINE 100 MG/ML-2 ML VIAL	250	RC	J3411	CPT				Both			12.6	5.67	1.64	11.34	1.65							Fee Schedule		9.32							Fee Schedule		1.64							Fee Schedule																				11.34							Fee Schedule																																															
THIAMINE 100MG/NS 100ML IVPB	636	RC	J3411	CPT				Both			38.85	17.48	1.64	34.97		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	28.75							Fee Schedule		1.64							Fee Schedule																				34.97							Fee Schedule																																															
THIAMINE VIT B1  5042 EDTA WHOLE BLD FZ	301	RC	84425	CPT				Both			248.85	111.98	18.87	223.97	18.87							Fee Schedule		23.59							Fee Schedule		21.87							Fee Schedule		21.23							Fee Schedule											223.97							Fee Schedule																				21.23							Fee Schedule																				
THIOCYANATE 879 SERUM	301	RC	84430	CPT				Both			74.55	33.55	1.48	67.1	10.34							Fee Schedule		12.93							Fee Schedule		11.98							Fee Schedule		11.63							Fee Schedule		1.6							Fee Schedule		67.1							Fee Schedule		1.84							Fee Schedule		1.48							Fee Schedule		11.63							Fee Schedule		1.84							Fee Schedule		1.48							Fee Schedule		
THIOPURINE 91745 METABOLITES	301	RC	83789	CPT				Both			464.1	208.85	1.48	417.69	17.36							Fee Schedule		24.11							Fee Schedule		24.83							Fee Schedule		24.11							Fee Schedule		1.6							Fee Schedule		417.69							Fee Schedule		1.84							Fee Schedule		1.48							Fee Schedule		24.11							Fee Schedule		1.84							Fee Schedule		1.48							Fee Schedule		
THIORIDAZINE 10 MG TABLET UD	250	RC	A9270	CPT				Both			4.2	1.89	0.01	24.41	0.01							Fee Schedule		3.11							Fee Schedule																				21.23							Fee Schedule		3.78							Fee Schedule		24.41							Fee Schedule		19.74							Fee Schedule											24.41							Fee Schedule		19.74							Fee Schedule		
THIORIDAZINE 25MG (MELLARIL) TABLET	250	RC	A9270	CPT				Both			6.3	2.84	0.01	13.37	0.01							Fee Schedule		4.66							Fee Schedule																				11.63							Fee Schedule		5.67							Fee Schedule		13.37							Fee Schedule		10.82							Fee Schedule											13.37							Fee Schedule		10.82							Fee Schedule		
THIORIDAZINE 50 MG TABLET UD	250	RC	A9270	CPT				Both			4.2	1.89	0.01	27.73	0.01							Fee Schedule		3.11							Fee Schedule																				24.11							Fee Schedule		3.78							Fee Schedule		27.73							Fee Schedule		22.42							Fee Schedule											27.73							Fee Schedule		22.42							Fee Schedule		
THIORIDAZINE MELLARIL 23232 SERUM	301	RC	80307	CPT				Both			147	66.15	51.72	132.3	51.72							Fee Schedule		64.65							Fee Schedule		64							Fee Schedule		62.14							Fee Schedule											132.3							Fee Schedule																				62.14							Fee Schedule																				
THIOTHIXENE 1MG (NAVANE) CAPSULE	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
THIOTHIXINE 1 MG CAPSULE UD	250	RC	A9270	CPT				Both			4.2	1.89	0.01	3.78	0.01							Fee Schedule		3.11							Fee Schedule																													3.78							Fee Schedule																																															
THIOTHIXINE 5 MG CAPSULE UD	250	RC	A9270	CPT				Both			4.2	1.89	0.01	71.46	0.01							Fee Schedule		3.11							Fee Schedule																				62.14							Fee Schedule		3.78							Fee Schedule		71.46							Fee Schedule		57.79							Fee Schedule											71.46							Fee Schedule		57.79							Fee Schedule		
THORA/PARACENTESIS TRAY #TPT1000SP	272	RC						Both			221	99.45	99.45	198.9	143.65							Fee Schedule		163.54							Fee Schedule																													198.9							Fee Schedule																																															
THORACENTESIS TRAY SAFETY TPT1000SP	272	RC						Both			108.15	48.67	48.67	97.34	70.3							Fee Schedule		80.03							Fee Schedule																													97.34							Fee Schedule																																															
THORACIC AP/LAT	320	RC	72070	CPT				Both			315	141.75	18.51	318	18.51							Fee Schedule		20.65							Fee Schedule											18.57							Fee Schedule											283.5							Fee Schedule																				318							Per Diem																				
THORACIC CATHETER ARGYLE 40FR 8888570572	272	RC						Both			14	6.3	6.3	12.6	9.1							Fee Schedule		10.36							Fee Schedule																													12.6							Fee Schedule																																															
THORACIC DUAL DRAIN SET (Y TUBING)	272	RC						Both			31.5	14.18	14.18	28.35	20.48							Fee Schedule		23.31							Fee Schedule																													28.35							Fee Schedule																																															
THORACIC MYELOGRAM	320	RC	72255	CPT				Both			689.85	310.43	42.38	620.87	42.38							Fee Schedule		53.12							Fee Schedule											122.62							Fee Schedule											620.87							Fee Schedule																				318							Per Diem																				
THORASIC SINGLE LEVEL EPD INJ	370	RC	64461	CPT				Both			283	127.35	112.73	254.7	112.73							Fee Schedule		209.42							Fee Schedule																													254.7							Fee Schedule																																															
THORAZINE CHLORPROMAZINE 882 SERUM	300	RC	80307	CPT				Both			82.95	37.33	37.33	74.66	51.72							Fee Schedule		64.65							Fee Schedule		64							Fee Schedule		62.14							Fee Schedule											74.66							Fee Schedule																				62.14							Fee Schedule																				
THORAZINE:100 MG TAB	250	RC	A9270	CPT				Both			1.58	0.71	0.01	1.42	0.01							Fee Schedule		1.17							Fee Schedule																													1.42							Fee Schedule																																															
THORAZINE:25MG TAB (CHLORPROMAZINE)	250	RC	A9270	CPT				Both			1.58	0.71	0.01	1.42	0.01							Fee Schedule		1.17							Fee Schedule																													1.42							Fee Schedule																																															
THUMB SPICA R AND L  2  ORTHO GLASS	270	RC						Both			170.1	76.55	57.79	153.09	110.57							Fee Schedule		125.87							Fee Schedule																				62.14							Fee Schedule		153.09							Fee Schedule		71.46							Fee Schedule		57.79							Fee Schedule											71.46							Fee Schedule		57.79							Fee Schedule		
THUMB SPICA R AND L  3  ORTHO GLASS	270	RC						Both			226.8	102.06	102.06	204.12	147.42							Fee Schedule		167.83							Fee Schedule																													204.12							Fee Schedule																																															
THUMB SPICA R AND L  4  ORTHO GLASS	270	RC						Both			283.5	127.58	127.58	255.15	184.28							Fee Schedule		209.79							Fee Schedule																													255.15							Fee Schedule																																															
THUMB SPICA R AND L  5  ORTHO GLASS	274	RC	A4590	CPT				Both			340.2	153.09	24.09	306.18		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	251.75							Fee Schedule											24.09							Fee Schedule											306.18							Fee Schedule																																															
THUMBKEEPER LG L	274	RC						Both			133	59.85	59.85	119.7		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	98.42							Fee Schedule																													119.7							Fee Schedule																																															
THUMBKEEPER LG R	274	RC						Both			133	59.85	59.85	119.7		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	98.42							Fee Schedule																													119.7							Fee Schedule																																															
THUMBKEEPER MED L	270	RC	L3808	CPT				Both			130	58.5	58.5	386.86	151.28							Fee Schedule		96.2							Fee Schedule		386.86							Fee Schedule																				117							Fee Schedule																																															
THUMBKEEPER MED R	274	RC						Both			130	58.5	58.5	117		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	96.2							Fee Schedule																													117							Fee Schedule																																															
THUMBKEEPER SM L	274	RC						Both			112.35	50.56	50.56	101.12		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	83.14							Fee Schedule																													101.12							Fee Schedule																																															
THUMBKEEPER SM R	270	RC	L3808	CPT				Both			128	57.6	57.6	431.93	151.28							Fee Schedule		94.72							Fee Schedule		386.86							Fee Schedule											375.59							Fee Schedule		115.2							Fee Schedule		431.93							Fee Schedule		349.3							Fee Schedule											431.93							Fee Schedule		349.3							Fee Schedule		
THYROGLOBULIN AB 267 SERUM	302	RC	86800	CPT				Both			90.3	40.64	14.14	81.27	14.14							Fee Schedule		17.67							Fee Schedule		16.39							Fee Schedule		15.91							Fee Schedule											81.27							Fee Schedule																				15.91							Fee Schedule																				
THYROGLOBULIN PANEL 30278 2ML SERUM	300	RC	84432	CPT				Both			90.3	40.64	14.28	81.27	14.28							Fee Schedule		17.84							Fee Schedule		16.54							Fee Schedule		16.06							Fee Schedule											81.27							Fee Schedule																				16.06							Fee Schedule																				
"THYROGLOBULIN, LC/MS 90810"	300	RC	84432	CPT				Both			438	197.1	14.28	431.93	14.28							Fee Schedule		17.84							Fee Schedule		16.54							Fee Schedule		16.06							Fee Schedule		375.59							Fee Schedule		394.2							Fee Schedule		431.93							Fee Schedule		349.3							Fee Schedule		16.06							Fee Schedule		431.93							Fee Schedule		349.3							Fee Schedule		
THYROID AUTOANTIBODIES 7260 SERUM	302	RC	86376	CPT				Both			154.35	69.46	12.93	138.92	12.93							Fee Schedule		16.17							Fee Schedule		14.99							Fee Schedule		14.55							Fee Schedule		15.91							Fee Schedule		138.92							Fee Schedule		18.3							Fee Schedule		14.8							Fee Schedule		14.55							Fee Schedule		18.3							Fee Schedule		14.8							Fee Schedule		
THYROID PEROXIDASE AB 5081 1ML SERUM	302	RC	86376	CPT				Both			248.85	111.98	12.93	223.97	12.93							Fee Schedule		16.17							Fee Schedule		14.99							Fee Schedule		14.55							Fee Schedule		16.06							Fee Schedule		223.97							Fee Schedule		18.47							Fee Schedule		14.94							Fee Schedule		14.55							Fee Schedule		18.47							Fee Schedule		14.94							Fee Schedule		
THYROID STIMULATING IMMUNOGLOBULIN 30551	301	RC	84445	CPT				Both			371.7	167.27	14.94	334.53	45.2							Fee Schedule		56.51							Fee Schedule		52.39							Fee Schedule		50.86							Fee Schedule		16.06							Fee Schedule		334.53							Fee Schedule		18.47							Fee Schedule		14.94							Fee Schedule		50.86							Fee Schedule		18.47							Fee Schedule		14.94							Fee Schedule		
THYROXINE BINDING GLOBUIN 870 SERUM	300	RC	84442	CPT				Both			90.3	40.64	13.14	81.27	13.14							Fee Schedule		16.43							Fee Schedule		15.22							Fee Schedule		14.78							Fee Schedule		14.55							Fee Schedule		81.27							Fee Schedule		16.73							Fee Schedule		13.53							Fee Schedule		14.78							Fee Schedule		16.73							Fee Schedule		13.53							Fee Schedule		
TIB/FIB LT	320	RC	73590	CPT				Both			315	141.75	13.53	318	16.47							Fee Schedule		19.35							Fee Schedule											15.04							Fee Schedule		14.55							Fee Schedule		283.5							Fee Schedule		16.73							Fee Schedule		13.53							Fee Schedule		318							Per Diem		16.73							Fee Schedule		13.53							Fee Schedule		
TIB/FIB RT	320	RC	73590	CPT				Both			315	141.75	15.04	318	16.47							Fee Schedule		19.35							Fee Schedule											15.04							Fee Schedule		50.86							Fee Schedule		283.5							Fee Schedule		58.49							Fee Schedule		47.3							Fee Schedule		318							Per Diem		58.49							Fee Schedule		47.3							Fee Schedule		
TIBC WITH TRANSFERRIN	301	RC	83550	CPT				Both			167.5	75.38	7.77	150.75	7.77							Fee Schedule		9.71							Fee Schedule		9							Fee Schedule		8.74							Fee Schedule		14.78							Fee Schedule		150.75							Fee Schedule		17							Fee Schedule		13.75							Fee Schedule		8.74							Fee Schedule		17							Fee Schedule		13.75							Fee Schedule		
TIBIAL END CAP	278	RC	C1713	CPT				Both			256.2	115.29	115.29	230.58		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	189.59							Fee Schedule																													230.58							Fee Schedule																																															
TIBIAL NAIL 10X34	278	RC	C1713	CPT				Both			1366.05	614.72	614.72	1229.45		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1010.88							Fee Schedule																													1229.45							Fee Schedule																																															
TIBIAL SCREW 5X35MM	278	RC	C1713	CPT				Both			341.25	153.56	8.13	307.13		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	252.53							Fee Schedule																				8.74							Fee Schedule		307.13							Fee Schedule		10.05							Fee Schedule		8.13							Fee Schedule											10.05							Fee Schedule		8.13							Fee Schedule		
TIBIAL SCREW 5X40MM	278	RC	C1713	CPT				Both			341.25	153.56	153.56	307.13		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	252.53							Fee Schedule																													307.13							Fee Schedule																																															
TIBIAL SCREW 5X45MM	278	RC	C1713	CPT				Both			341.25	153.56	153.56	307.13		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	252.53							Fee Schedule																													307.13							Fee Schedule																																															
TICE BCG POWDER FOR SUSP 50MG VIAL	636	RC	J9030	CPT				Both			611.58	275.21	3.38	550.42		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	3.39							Fee Schedule		3.38							Fee Schedule																				550.42							Fee Schedule																																															
TICK & OTHER ARTHROPODS ID 3946	306	RC	87168	CPT				Both			132	59.4	3.79	118.8	3.79							Fee Schedule		4.75							Fee Schedule		4.4							Fee Schedule		4.27							Fee Schedule											118.8							Fee Schedule																																															
TICLODIPINE 250 MG TABLET UD	250	RC	A9270	CPT				Both			7.35	3.31	0.01	6.62	0.01							Fee Schedule		5.44							Fee Schedule																													6.62							Fee Schedule																																															
TICLOPIDINE 30419 SERUM 2ML FROZEN	301	RC	80299	CPT				Both			177.45	79.85	3.05	159.71	13.42							Fee Schedule		18.64							Fee Schedule		19.2							Fee Schedule		18.64							Fee Schedule		3.28							Fee Schedule		159.71							Fee Schedule		3.77							Fee Schedule		3.05							Fee Schedule		18.64							Fee Schedule		3.77							Fee Schedule		3.05							Fee Schedule		
TIGAN 100 MG CAP.	250	RC	A9270	CPT				Both			4.2	1.89	0.01	4.91	0.01							Fee Schedule		3.11							Fee Schedule																				4.27							Fee Schedule		3.78							Fee Schedule		4.91							Fee Schedule		3.97							Fee Schedule											4.91							Fee Schedule		3.97							Fee Schedule		
TIGAN 100 MG/ML - 2 ML AMP	636	RC	J3250	CPT				Both			17.85	8.03	2.96	64.82		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	13.21							Fee Schedule		64.82							Fee Schedule		2.96							Fee Schedule											16.07							Fee Schedule																																															
TIGECYCLINE 100MG/100ML NS IVPB	636	RC	J3243	CPT				Both			788.76	354.94	0.53	709.88		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	583.68							Fee Schedule		0.53							Fee Schedule											18.64							Fee Schedule		709.88							Fee Schedule		21.44							Fee Schedule		17.34							Fee Schedule											21.44							Fee Schedule		17.34							Fee Schedule		
TIGECYCLINE 50MG VIAL	636	RC	J3243	CPT				Both			561.6	252.72	0.53	505.44		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	415.58							Fee Schedule		0.53							Fee Schedule																				505.44							Fee Schedule																																															
TIGECYCLINE 50MG/100ML NS IVPB	636	RC	J3243	CPT				Both			592.2	266.49	0.53	532.98		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	438.23							Fee Schedule		0.53							Fee Schedule											62.94							Fee Schedule		532.98							Fee Schedule		72.38							Fee Schedule		58.53							Fee Schedule											72.38							Fee Schedule		58.53							Fee Schedule		
TIMENTIN 3.1 GM VIAL	250	RC						Both			56.7	25.52	0.48	51.03	36.86							Fee Schedule		41.96							Fee Schedule																				0.52							Fee Schedule		51.03							Fee Schedule		0.59							Fee Schedule		0.48							Fee Schedule											0.59							Fee Schedule		0.48							Fee Schedule		
TIMENTIN 3.1 GM VIAL	250	RC	S0040	CPT				Both			41.45	18.65	0.48	37.31	13.28							Fee Schedule		30.67							Fee Schedule																				0.52							Fee Schedule		37.31							Fee Schedule		0.59							Fee Schedule		0.48							Fee Schedule											0.59							Fee Schedule		0.48							Fee Schedule		
TIMOLOL 0.25% (TIMOPTIC) OPTH SOLUTION	250	RC	A9270	CPT				Both			47.25	21.26	0.01	42.53	0.01							Fee Schedule		34.97							Fee Schedule																				0.52							Fee Schedule		42.53							Fee Schedule		0.59							Fee Schedule		0.48							Fee Schedule											0.59							Fee Schedule		0.48							Fee Schedule		
TIMOLOL O.5% (TIMOPTIC) OPTH SOL 5ML	250	RC	A9270	CPT				Both			53.55	24.1	0.01	48.2	0.01							Fee Schedule		39.63							Fee Schedule																													48.2							Fee Schedule																																															
TIRCRON 2.0  3256-51	272	RC						Both			21	9.45	9.45	18.9	13.65							Fee Schedule		15.54							Fee Schedule																													18.9							Fee Schedule																																															
TISSEEL (FIBRINOTHERM)	272	RC						Both			708.75	318.94	318.94	637.88	460.69							Fee Schedule		524.48							Fee Schedule																													637.88							Fee Schedule																																															
TISSUE CULTURE SKIN OR OTHER SOLID TISSU	310	RC	88233	CPT				Both			600	270	125.09	540	125.09							Fee Schedule		156.36							Fee Schedule		144.95							Fee Schedule		140.73							Fee Schedule											540							Fee Schedule																																															
TISSUE IN SITU HYBRIDIZATION INT & RPT	312	RC	88365	CPT				Both			263.55	118.6	88.88	237.2	88.88							Fee Schedule		120.66							Fee Schedule											119.47							Fee Schedule											237.2							Fee Schedule																																															
TISSUE MANIP (5MM)	272	RC						Both			358.05	161.12	161.12	322.25	232.73							Fee Schedule		264.96							Fee Schedule																													322.25							Fee Schedule																																															
TISSUE TRANSGLUTAMINASE 11073 1ML SERUM	301	RC	83516	CPT				Both			150.15	67.57	10.25	161.84	10.25							Fee Schedule		12.81							Fee Schedule		11.88							Fee Schedule		11.53							Fee Schedule		140.73							Fee Schedule		135.14							Fee Schedule		161.84							Fee Schedule		130.88							Fee Schedule		11.53							Fee Schedule		161.84							Fee Schedule		130.88							Fee Schedule		
TISSUE TRAP #003853-902 (OLYMPUS)	270	RC						Both			30	13.5	13.5	27	19.5							Fee Schedule		22.2							Fee Schedule																													27							Fee Schedule																																															
TITANIUM 8329 W/B EDTA ROYAL BLUE TUBE	300	RC	83018	CPT				Both			131.25	59.06	19.53	118.13	19.53							Fee Schedule		24.41							Fee Schedule		22.62							Fee Schedule		21.96							Fee Schedule											118.13							Fee Schedule																				21.96							Fee Schedule																				
TIZANIDINE 2MG (ZANAFLEX) TABLET	250	RC	A9270	CPT				Both			6.3	2.84	0.01	13.26	0.01							Fee Schedule		4.66							Fee Schedule																				11.53							Fee Schedule		5.67							Fee Schedule		13.26							Fee Schedule		10.72							Fee Schedule											13.26							Fee Schedule		10.72							Fee Schedule		
TIZANIDINE 4MG (ZANAFLEX) TABLET	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
T-M JOINTS	320	RC	70330	CPT				Both			315	141.75	20.42	318	28.41							Fee Schedule		33.63							Fee Schedule											23.76							Fee Schedule		21.96							Fee Schedule		283.5							Fee Schedule		25.25							Fee Schedule		20.42							Fee Schedule		318							Per Diem		25.25							Fee Schedule		20.42							Fee Schedule		
TN DONOR HEMI CUT FEMUR GRAFT 121MM >	278	RC	C1762	CPT				Both			2898	1304.1	1304.1	2608.2		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	2144.52							Fee Schedule																													2608.2							Fee Schedule																																															
TN DONOR HEMI SHAFT FEMUR	278	RC	C1762	CPT				Both			1871.1	842	842	1683.99		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1384.61							Fee Schedule																													1683.99							Fee Schedule																																															
TNF ALPHA  34485 1ML SERUM FROZEN	301	RC	83520	CPT				Both			195.3	87.89	12.43	175.77	12.43							Fee Schedule		17.27							Fee Schedule		17.79							Fee Schedule		17.27							Fee Schedule											175.77							Fee Schedule																				17.27							Fee Schedule																				
TNKase 25 MG	636	RC	J3101	CPT				Both			30766.26	13844.82	192.58	27689.63		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	197.45							Fee Schedule		192.58							Fee Schedule																				27689.63							Fee Schedule																																															
TNKase 50 MG	636	RC	J3101	CPT				Both			30766.26	13844.82	192.58	27689.63		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	197.45							Fee Schedule		192.58							Fee Schedule																				27689.63							Fee Schedule																																															
TOBRA/ DEXAMETH (TOBRADEX)  OPTH SUSP	250	RC	A9270	CPT				Both			390.06	175.53	0.01	351.05	0.01							Fee Schedule		288.64							Fee Schedule																				17.27							Fee Schedule		351.05							Fee Schedule		19.86							Fee Schedule		16.06							Fee Schedule											19.86							Fee Schedule		16.06							Fee Schedule		
TOBRADEX OPTH OINTMENT- 3.5GM	250	RC	A9270	CPT				Both			73.5	33.08	0.01	215.02	0.01							Fee Schedule		54.39							Fee Schedule																				186.97							Fee Schedule		66.15							Fee Schedule		215.02							Fee Schedule		173.88							Fee Schedule											215.02							Fee Schedule		173.88							Fee Schedule		
TOBRAMYCIN  70MG/NS 100ML IVPB	250	RC	J3260	CPT				Both			101.85	45.83	2.25	215.02	3.69							Fee Schedule		75.37							Fee Schedule		2.25							Fee Schedule		8.66							Fee Schedule		186.97							Fee Schedule		91.67							Fee Schedule		215.02							Fee Schedule		173.88							Fee Schedule											215.02							Fee Schedule		173.88							Fee Schedule		
TOBRAMYCIN  80MG/NS 100ML IVPB	636	RC	J3260	CPT				Both			13.65	6.14	2.25	12.29		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	10.1							Fee Schedule		2.25							Fee Schedule		8.66							Fee Schedule											12.29							Fee Schedule																																															
TOBRAMYCIN  PEAK	301	RC	80200	CPT				Both			98.7	44.42	14.34	88.83	14.34							Fee Schedule		17.92							Fee Schedule		16.61							Fee Schedule		16.13							Fee Schedule											88.83							Fee Schedule																				16.13							Fee Schedule																				
TOBRAMYCIN  RANDOM	301	RC	80200	CPT				Both			98.7	44.42	2.03	88.83	14.34							Fee Schedule		17.92							Fee Schedule		16.61							Fee Schedule		16.13							Fee Schedule		2.19							Fee Schedule		88.83							Fee Schedule		2.51							Fee Schedule		2.03							Fee Schedule		16.13							Fee Schedule		2.51							Fee Schedule		2.03							Fee Schedule		
TOBRAMYCIN  TROUGH	301	RC	80200	CPT				Both			98.7	44.42	2.03	88.83	14.34							Fee Schedule		17.92							Fee Schedule		16.61							Fee Schedule		16.13							Fee Schedule		2.19							Fee Schedule		88.83							Fee Schedule		2.51							Fee Schedule		2.03							Fee Schedule		16.13							Fee Schedule		2.51							Fee Schedule		2.03							Fee Schedule		
TOBRAMYCIN (TOBREX)  OPTH SOLUTION	250	RC	A9270	CPT				Both			47.25	21.26	0.01	42.53	0.01							Fee Schedule		34.97							Fee Schedule																				16.13							Fee Schedule		42.53							Fee Schedule		18.55							Fee Schedule		15							Fee Schedule											18.55							Fee Schedule		15							Fee Schedule		
TOBRAMYCIN : 1.2 GM INJECTION	636	RC	J3260	CPT				Both			236.25	106.31	2.25	212.63		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	174.83							Fee Schedule		2.25							Fee Schedule		8.66							Fee Schedule		16.13							Fee Schedule		212.63							Fee Schedule		18.55							Fee Schedule		15							Fee Schedule											18.55							Fee Schedule		15							Fee Schedule		
TOBRAMYCIN : 80 MG/2ML INJECTION	636	RC	J3260	CPT				Both			13.65	6.14	2.25	18.55		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	10.1							Fee Schedule		2.25							Fee Schedule		8.66							Fee Schedule		16.13							Fee Schedule		12.29							Fee Schedule		18.55							Fee Schedule		15							Fee Schedule											18.55							Fee Schedule		15							Fee Schedule		
TOBRAMYCIN 1.2 GM/30ML INJECTION	636	RC	J3260	CPT				Both			950.25	427.61	2.25	855.23		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	703.19							Fee Schedule		2.25							Fee Schedule		8.66							Fee Schedule											855.23							Fee Schedule																																															
TOBRAMYCIN 100MG/NS 100ML	636	RC	J3260	CPT				Both			101.85	45.83	2.03	91.67		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	75.37							Fee Schedule		2.25							Fee Schedule		8.66							Fee Schedule		2.19							Fee Schedule		91.67							Fee Schedule		2.51							Fee Schedule		2.03							Fee Schedule											2.51							Fee Schedule		2.03							Fee Schedule		
TOBRAMYCIN 110MG/NS 100ML	250	RC	J3260	CPT				Both			101.85	45.83	2.03	91.67	3.69							Fee Schedule		75.37							Fee Schedule		2.25							Fee Schedule		8.66							Fee Schedule		2.19							Fee Schedule		91.67							Fee Schedule		2.51							Fee Schedule		2.03							Fee Schedule											2.51							Fee Schedule		2.03							Fee Schedule		
TOBRAMYCIN 120MG/NS 100ML	636	RC	J3260	CPT				Both			101.85	45.83	2.03	91.67		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	75.37							Fee Schedule		2.25							Fee Schedule		8.66							Fee Schedule		2.19							Fee Schedule		91.67							Fee Schedule		2.51							Fee Schedule		2.03							Fee Schedule											2.51							Fee Schedule		2.03							Fee Schedule		
TOBRAMYCIN 140MG/NS 100ML	636	RC	J3260	CPT				Both			101.85	45.83	2.03	91.67		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	75.37							Fee Schedule		2.25							Fee Schedule		8.66							Fee Schedule		2.19							Fee Schedule		91.67							Fee Schedule		2.51							Fee Schedule		2.03							Fee Schedule											2.51							Fee Schedule		2.03							Fee Schedule		
TOBRAMYCIN 160MG/NS 100ML	636	RC	J3260	CPT				Both			101.85	45.83	2.03	91.67		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	75.37							Fee Schedule		2.25							Fee Schedule		8.66							Fee Schedule		2.19							Fee Schedule		91.67							Fee Schedule		2.51							Fee Schedule		2.03							Fee Schedule											2.51							Fee Schedule		2.03							Fee Schedule		
TOBRAMYCIN 180MG/NS 100ML	636	RC	J3260	CPT				Both			13.65	6.14	2.03	12.29		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	10.1							Fee Schedule		2.25							Fee Schedule		8.66							Fee Schedule		2.19							Fee Schedule		12.29							Fee Schedule		2.51							Fee Schedule		2.03							Fee Schedule											2.51							Fee Schedule		2.03							Fee Schedule		
TOBRAMYCIN 200MG/NS 100ML IVPB	636	RC	J3260	CPT				Both			101.85	45.83	2.03	91.67		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	75.37							Fee Schedule		2.25							Fee Schedule		8.66							Fee Schedule		2.19							Fee Schedule		91.67							Fee Schedule		2.51							Fee Schedule		2.03							Fee Schedule											2.51							Fee Schedule		2.03							Fee Schedule		
TOBRAMYCIN 240MG/NS 100ML IVPB	636	RC	J3260	CPT				Both			13.65	6.14	2.03	12.29		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	10.1							Fee Schedule		2.25							Fee Schedule		8.66							Fee Schedule		2.19							Fee Schedule		12.29							Fee Schedule		2.51							Fee Schedule		2.03							Fee Schedule											2.51							Fee Schedule		2.03							Fee Schedule		
TOBRAMYCIN 80 MG/100ML PREMIX	636	RC	J3260	CPT				Both			38.39	17.28	2.03	34.55		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	28.41							Fee Schedule		2.25							Fee Schedule		8.66							Fee Schedule		2.19							Fee Schedule		34.55							Fee Schedule		2.51							Fee Schedule		2.03							Fee Schedule											2.51							Fee Schedule		2.03							Fee Schedule		
TOBREX OPTH OINT	250	RC	A9270	CPT				Both			231.75	104.29	0.01	208.58	0.01							Fee Schedule		171.5							Fee Schedule																				2.19							Fee Schedule		208.58							Fee Schedule		2.51							Fee Schedule		2.03							Fee Schedule											2.51							Fee Schedule		2.03							Fee Schedule		
TOCAINIDE 400 MG TABLET UD	250	RC	A9270	CPT				Both			4.2	1.89	0.01	3.78	0.01							Fee Schedule		3.11							Fee Schedule																				2.19							Fee Schedule		3.78							Fee Schedule		2.51							Fee Schedule		2.03							Fee Schedule											2.51							Fee Schedule		2.03							Fee Schedule		
TOCAINIDE PROXLIXIN 34524  SERUM	301	RC	80299	CPT				Both			206.85	93.08	2.03	186.17	13.42							Fee Schedule		18.64							Fee Schedule		19.2							Fee Schedule		18.64							Fee Schedule		2.19							Fee Schedule		186.17							Fee Schedule		2.51							Fee Schedule		2.03							Fee Schedule		18.64							Fee Schedule		2.51							Fee Schedule		2.03							Fee Schedule		
TOCILIZUMAB 400MG VIAL (ACTEMRA)	636	RC	J3262	CPT				Both			9105.66	4097.55	5.53	8195.09		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	5.53							Fee Schedule		5.78							Fee Schedule																				8195.09							Fee Schedule																																															
TOCILIZUMAB 800MG/100ML NS IVPB	636	RC	J3262	CPT				Both			8715.92	3922.16	5.53	7844.33		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	5.53							Fee Schedule		5.78							Fee Schedule																				7844.33							Fee Schedule																																															
TOES LT	320	RC	73660	CPT				Both			315	141.75	11.95	318	17.64							Fee Schedule		20							Fee Schedule											11.95							Fee Schedule		18.64							Fee Schedule		283.5							Fee Schedule		21.44							Fee Schedule		17.34							Fee Schedule		318							Per Diem		21.44							Fee Schedule		17.34							Fee Schedule		
TOES RT	320	RC	73660	CPT				Both			315	141.75	5.22	318	17.64							Fee Schedule		20							Fee Schedule											11.95							Fee Schedule		5.61							Fee Schedule		283.5							Fee Schedule		6.45							Fee Schedule		5.22							Fee Schedule		318							Per Diem		6.45							Fee Schedule		5.22							Fee Schedule		
TOFACITINIB (XELJANZ) 5MG TABLET	636	RC	J8610	CPT				Both			296	133.2	0.16	266.4		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	219.04							Fee Schedule		0.16							Fee Schedule											5.61							Fee Schedule		266.4							Fee Schedule		6.45							Fee Schedule		5.22							Fee Schedule											6.45							Fee Schedule		5.22							Fee Schedule		
TOGA HOOD (STRYKER INSTRUMENTS) 400-502	272	RC						Both			68.25	30.71	30.71	61.43	44.36							Fee Schedule		50.51							Fee Schedule																													61.43							Fee Schedule																																															
TOGAS	272	RC						Both			155.4	69.93	69.93	139.86	101.01							Fee Schedule		115							Fee Schedule																													139.86							Fee Schedule																																															
TOLTERODINE (DETROL) 1MG TABLET	250	RC	A9270	CPT				Both			8.87	3.99	0.01	7.98	0.01							Fee Schedule		6.56							Fee Schedule																				0.15							Fee Schedule		7.98							Fee Schedule		0.18							Fee Schedule		0.14							Fee Schedule											0.18							Fee Schedule		0.14							Fee Schedule		
TOLTERODINE ER 2MG (DETROL LA) CAPSULE	250	RC	A9270	CPT				Both			16.8	7.56	0.01	15.12	0.01							Fee Schedule		12.43							Fee Schedule																													15.12							Fee Schedule																																															
TOMCAT ARTHROSCOPY BLADE (STRYKER ENDOSC	272	RC						Both			197.4	88.83	88.83	177.66	128.31							Fee Schedule		146.08							Fee Schedule																													177.66							Fee Schedule																																															
TOMO RENAL	320	RC	74415	CPT				Both			414.75	186.64	60.04	373.28	91.58							Fee Schedule		109.29							Fee Schedule											60.04							Fee Schedule											373.28							Fee Schedule																				318							Per Diem																				
TOMO UNLISTED	350	RC	76100	CPT				Both			2100	945	35.44	2478	956							Per Diem		57.66							Fee Schedule											35.44							Fee Schedule											1890							Fee Schedule																				2478							Case Rate																				
TOMOGRAM LUNG	320	RC	76102	CPT				Both			315	141.75	92.33	318	92.33							Fee Schedule		233.1							Fee Schedule																													283.5							Fee Schedule																				318							Per Diem																				
TONSIL SPONGE MED	272	RC						Both			7.35	3.31	3.31	6.62	4.78							Fee Schedule		5.44							Fee Schedule																													6.62							Fee Schedule																																															
TONSIL SPONGES 30-037 (DEROYAL)	272	RC						Both			3	1.35	1.35	2.7	1.95							Fee Schedule		2.22							Fee Schedule																													2.7							Fee Schedule																																															
TONSIL SPONGES LG	272	RC						Both			7.35	3.31	3.31	6.62	4.78							Fee Schedule		5.44							Fee Schedule																													6.62							Fee Schedule																																															
TONSIL TIP SUC 3491	272	RC						Both			2	0.9	0.9	1.8	1.3							Fee Schedule		1.48							Fee Schedule																													1.8							Fee Schedule																																															
TOOMEY SYRINGE	272	RC						Both			6.3	2.84	2.84	5.67	4.1							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
TOOMEY SYRINGES  MEDLINE DYND20323	270	RC	A4213	CPT				Both			5	2.25	0.52	4.5	0.52							Fee Schedule		3.7							Fee Schedule																													4.5							Fee Schedule																																															
TOPICORT LP 0.05% CREAM- 15GM	250	RC	A9270	CPT				Both			126	56.7	0.01	113.4	0.01							Fee Schedule		93.24							Fee Schedule																													113.4							Fee Schedule																																															
TOPIRAMATE  25MG (TOPAMAX) TABLET	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
TOPIRAMATE 100MG (TOPAMAX) TABLET	250	RC	A9270	CPT				Both			12.6	5.67	0.01	11.34	0.01							Fee Schedule		9.32							Fee Schedule																													11.34							Fee Schedule																																															
TOPIRAMATE TOPAMAX  PK  30965  1ML S RT	301	RC	80201	CPT				Both			127.05	57.17	10.6	114.35	10.6							Fee Schedule		13.24							Fee Schedule		12.28							Fee Schedule		11.92							Fee Schedule											114.35							Fee Schedule																				11.92							Fee Schedule																				
TOPIRAMATE TOPAMAX RANDOM 30965 RED TOP	301	RC	80201	CPT				Both			127.05	57.17	10.6	114.35	10.6							Fee Schedule		13.24							Fee Schedule		12.28							Fee Schedule		11.92							Fee Schedule											114.35							Fee Schedule																				11.92							Fee Schedule																				
TOPIRAMATE TOPAMAX TROUGH 30965 1ML S RT	301	RC	80201	CPT				Both			127.05	57.17	10.6	114.35	10.6							Fee Schedule		13.24							Fee Schedule		12.28							Fee Schedule		11.92							Fee Schedule											114.35							Fee Schedule																				11.92							Fee Schedule																				
TORCH IGG PANEL 7805 SERUM	300	RC						Both			10.5	4.73	4.73	13.71	6.83							Fee Schedule		7.77							Fee Schedule																				11.92							Fee Schedule		9.45							Fee Schedule		13.71							Fee Schedule		11.09							Fee Schedule											13.71							Fee Schedule		11.09							Fee Schedule		
TORCH IGM PANEL 6444 SERUM	300	RC						Both			10.5	4.73	4.73	13.71	6.83							Fee Schedule		7.77							Fee Schedule																				11.92							Fee Schedule		9.45							Fee Schedule		13.71							Fee Schedule		11.09							Fee Schedule											13.71							Fee Schedule		11.09							Fee Schedule		
TORSEMIDE 10 MG TABLET UD	250	RC	A9270	CPT				Both			4.2	1.89	0.01	13.71	0.01							Fee Schedule		3.11							Fee Schedule																				11.92							Fee Schedule		3.78							Fee Schedule		13.71							Fee Schedule		11.09							Fee Schedule											13.71							Fee Schedule		11.09							Fee Schedule		
TORSEMIDE 100 MG TABLET UD	250	RC	A9270	CPT				Both			6.8	3.06	0.01	6.12	0.01							Fee Schedule		5.03							Fee Schedule																													6.12							Fee Schedule																																															
TORSEMIDE 10MG (DEMADEX) TABLET	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
TORSEMIDE 20MG (DEMADEX) TABLET	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
TOTAL HIP CANCELLOUS BONE SCREW 6.5MM	278	RC	C1713	CPT				Both			311.85	140.33	140.33	280.67		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	230.77							Fee Schedule																													280.67							Fee Schedule																																															
TOTAL HIP CEMENTRALIZER DEPUY	278	RC	C1776	CPT				Both			305.55	137.5	137.5	275		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	226.11							Fee Schedule																													275							Fee Schedule																																															
TOTAL HIP CML FEMORAL COMP DEPUY	278	RC	C1776	CPT				Both			7229.25	3253.16	3253.16	6506.33		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	5349.65							Fee Schedule																													6506.33							Fee Schedule																																															
TOTAL HIP HIP BALL DEPUY	278	RC	C1776	CPT				Both			1622.25	730.01	730.01	1460.03		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1200.47							Fee Schedule																													1460.03							Fee Schedule																																															
TOTAL HIP RESPONSE 209 HIP SYSTEM	278	RC	C1776	CPT				Both			2359.35	1061.71	1061.71	2123.42		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1745.92							Fee Schedule																													2123.42							Fee Schedule																																															
TOTAL HIP SECTOR ACETABULAR COMP.	278	RC	C1776	CPT				Both			4027.8	1812.51	1812.51	3625.02		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	2980.57							Fee Schedule																													3625.02							Fee Schedule																																															
TOTAL KNEE LCS BLADE DEPUY	272	RC						Both			300.3	135.14	135.14	270.27	195.2							Fee Schedule		222.22							Fee Schedule																													270.27							Fee Schedule																																															
TOTAL KNEE PATELLA COMPONENT	278	RC	C1776	CPT				Both			2629.2	1183.14	1183.14	2366.28		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1945.61							Fee Schedule																													2366.28							Fee Schedule																																															
TOTAL KNEE POLY PLATFORM COMPENENT	278	RC	C1776	CPT				Both			2646	1190.7	1190.7	2381.4		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1958.04							Fee Schedule																													2381.4							Fee Schedule																																															
TOTAL KNEE SUPPORT Q93-1888	274	RC	L3808	CPT				Both			1152.9	518.81	386.86	1037.61		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	853.15							Fee Schedule		386.86							Fee Schedule																				1037.61							Fee Schedule																																															
TOTAL PROTEIN	301	RC	84155	CPT				Both			29.4	13.23	3.26	26.46	3.26							Fee Schedule		4.07							Fee Schedule		3.78							Fee Schedule		3.67							Fee Schedule											26.46							Fee Schedule																				3.67							Fee Schedule																				
TOTAL PROTEIN URINE	301	RC	84156	CPT				Both			45.15	20.32	3.26	40.64	3.26							Fee Schedule		4.07							Fee Schedule		3.78							Fee Schedule		3.67							Fee Schedule											40.64							Fee Schedule																				3.67							Fee Schedule																				
TOXIC SHOCK  ANTIBODY PANEL15998	306	RC	86609	CPT				Both			325.5	146.48	11.45	431.93	11.45							Fee Schedule		14.31							Fee Schedule		13.27							Fee Schedule		12.88							Fee Schedule		375.59							Fee Schedule		292.95							Fee Schedule		431.93							Fee Schedule		349.3							Fee Schedule		12.88							Fee Schedule		431.93							Fee Schedule		349.3							Fee Schedule		
TOXOCARA ANTIBODY 34304 SERUM 1 ML	302	RC	86682	CPT				Both			178.5	80.33	3.41	160.65	11.56							Fee Schedule		14.45							Fee Schedule		13.4							Fee Schedule		13.01							Fee Schedule		3.67							Fee Schedule		160.65							Fee Schedule		4.22							Fee Schedule		3.41							Fee Schedule		13.01							Fee Schedule		4.22							Fee Schedule		3.41							Fee Schedule		
TOXOPLASMA GONDII (IGG) CSF 10666	302	RC	86777	CPT				Both			186	83.7	3.41	167.4	12.79							Fee Schedule		15.99							Fee Schedule		14.82							Fee Schedule		14.39							Fee Schedule		3.67							Fee Schedule		167.4							Fee Schedule		4.22							Fee Schedule		3.41							Fee Schedule		14.39							Fee Schedule		4.22							Fee Schedule		3.41							Fee Schedule		
TOXOPLASMA TITER IGG 3679 SERUM	302	RC	86777	CPT				Both			117.6	52.92	11.98	105.84	12.79							Fee Schedule		15.99							Fee Schedule		14.82							Fee Schedule		14.39							Fee Schedule		12.88							Fee Schedule		105.84							Fee Schedule		14.81							Fee Schedule		11.98							Fee Schedule		14.39							Fee Schedule		14.81							Fee Schedule		11.98							Fee Schedule		
TOXOPLASMA TITER IGM 8636 SERUM	302	RC	86778	CPT				Both			98.7	44.42	12.1	88.83	12.8							Fee Schedule		16.01							Fee Schedule		14.84							Fee Schedule		14.41							Fee Schedule		13.01							Fee Schedule		88.83							Fee Schedule		14.96							Fee Schedule		12.1							Fee Schedule		14.41							Fee Schedule		14.96							Fee Schedule		12.1							Fee Schedule		
TPMT ACTIVITY 18831	301	RC	82657	CPT				Both			534.45	240.5	13.38	481.01	16.05							Fee Schedule		22.17							Fee Schedule		22.84							Fee Schedule		22.17							Fee Schedule		14.39							Fee Schedule		481.01							Fee Schedule		16.55							Fee Schedule		13.38							Fee Schedule		22.17							Fee Schedule		16.55							Fee Schedule		13.38							Fee Schedule		
TPN ADMIX	250	RC						Both			10.5	4.73	4.73	16.55	6.83							Fee Schedule		7.77							Fee Schedule																				14.39							Fee Schedule		9.45							Fee Schedule		16.55							Fee Schedule		13.38							Fee Schedule											16.55							Fee Schedule		13.38							Fee Schedule		
TPN MULTIPLE ELECTROLYTES-20ML VIAL	250	RC	J7131	CPT				Both			24.15	10.87	0.03	21.74	0.03							Fee Schedule		17.87							Fee Schedule																				14.41							Fee Schedule		21.74							Fee Schedule		16.57							Fee Schedule		13.4							Fee Schedule											16.57							Fee Schedule		13.4							Fee Schedule		
TR35 SKIN STAPLES	272	RC						Both			86.1	38.75	20.62	77.49	55.97							Fee Schedule		63.71							Fee Schedule																				22.17							Fee Schedule		77.49							Fee Schedule		25.5							Fee Schedule		20.62							Fee Schedule											25.5							Fee Schedule		20.62							Fee Schedule		
TRAb (TSH RECEPTOR AB) 38683	301	RC	83520	CPT				Both			73.5	33.08	12.43	66.15	12.43							Fee Schedule		17.27							Fee Schedule		17.79							Fee Schedule		17.27							Fee Schedule											66.15							Fee Schedule																				17.27							Fee Schedule																				
TRAC CARE TRAY	272	RC						Both			9.45	4.25	4.25	8.51	6.14							Fee Schedule		6.99							Fee Schedule																													8.51							Fee Schedule																																															
TRAC LGE BLACK DRESSING M6275053/5	272	RC	A6550	CPT				Both			142.8	64.26	19.58	128.52	19.58							Fee Schedule		105.67							Fee Schedule		32.29							Fee Schedule		23.89							Fee Schedule											128.52							Fee Schedule																																															
TRAC TUBE SHILEY	272	RC						Both			169.05	76.07	16.06	152.15	109.88							Fee Schedule		125.1							Fee Schedule																				17.27							Fee Schedule		152.15							Fee Schedule		19.86							Fee Schedule		16.06							Fee Schedule											19.86							Fee Schedule		16.06							Fee Schedule		
TRACE ELEMENTS 1ML INJECTION	250	RC	A9270	CPT				Both			11.55	5.2	0.01	10.4	0.01							Fee Schedule		8.55							Fee Schedule																													10.4							Fee Schedule																																															
TRACER WIREGUIDE TMST-480	272	RC	C1769	CPT				Both			352.8	158.76	29.16	317.52	154.26							Fee Schedule		261.07							Fee Schedule																				31.35							Fee Schedule		317.52							Fee Schedule		36.05							Fee Schedule		29.16							Fee Schedule											36.05							Fee Schedule		29.16							Fee Schedule		
TRACH BUTTON 6DCP (STOCK)	272	RC	A7524	CPT				Both			22.2	9.99	9.99	113.64	69.7							Fee Schedule		16.43							Fee Schedule		113.64							Fee Schedule		67.43							Fee Schedule											19.98							Fee Schedule																																															
TRACH BUTTON 8DCP	272	RC	A7524	CPT				Both			15.75	7.09	7.09	113.64	69.7							Fee Schedule		11.66							Fee Schedule		113.64							Fee Schedule		67.43							Fee Schedule											14.18							Fee Schedule																																															
TRACH BUTTON NORRIS 19X12MM (PILLINGWECK	272	RC	A7524	CPT				Both			163.8	73.71	67.43	147.42	69.7							Fee Schedule		121.21							Fee Schedule		113.64							Fee Schedule		67.43							Fee Schedule											147.42							Fee Schedule																																															
TRACH CARE TRAY DYND40582	272	RC	A4629	CPT				Both			4.9	2.21	2.21	126.88	4.18							Fee Schedule		3.63							Fee Schedule		6.83							Fee Schedule		5.23							Fee Schedule		110.33							Fee Schedule		4.41							Fee Schedule		126.88							Fee Schedule		102.61							Fee Schedule											126.88							Fee Schedule		102.61							Fee Schedule		
TRACH KIT PERCUTANEOUS SIZE 8 #535-080	272	RC						Both			866.25	389.81	102.61	779.63	563.06							Fee Schedule		641.03							Fee Schedule																				110.33							Fee Schedule		779.63							Fee Schedule		126.88							Fee Schedule		102.61							Fee Schedule											126.88							Fee Schedule		102.61							Fee Schedule		
TRACH MASK ADULT #301-184  (TRIANIM)	271	RC						Both			5	2.25	2.25	126.88	3.25							Fee Schedule		3.7							Fee Schedule																				110.33							Fee Schedule		4.5							Fee Schedule		126.88							Fee Schedule		102.61							Fee Schedule											126.88							Fee Schedule		102.61							Fee Schedule		
TRACH MASK RENT	272	RC	A7525	CPT				Both			8.4	3.78	1.8	7.62	1.86							Fee Schedule		6.22							Fee Schedule		3.03							Fee Schedule		1.8							Fee Schedule		6.63							Fee Schedule		7.56							Fee Schedule		7.62							Fee Schedule		6.17							Fee Schedule											7.62							Fee Schedule		6.17							Fee Schedule		
TRACH TUBE HOLDER #240	272	RC	A4625	CPT				Both			10	4.5	4.5	9	5.3							Fee Schedule		7.4							Fee Schedule		8.64							Fee Schedule		6.62							Fee Schedule											9							Fee Schedule																																															
TRACKIE TIES	271	RC						Both			3.15	1.42	1.42	2.84	2.05							Fee Schedule		2.33							Fee Schedule																													2.84							Fee Schedule																																															
TRAMADOL 50 MG (ULTRAM) TABLET	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																				2.94							Fee Schedule		5.67							Fee Schedule		3.38							Fee Schedule		2.73							Fee Schedule											3.38							Fee Schedule		2.73							Fee Schedule		
TRANDOLAPRIL 1MG (MAVIK) TABLET	250	RC	A9270	CPT				Both			6.3	2.84	0.01	9.65	0.01							Fee Schedule		4.66							Fee Schedule																				8.39							Fee Schedule		5.67							Fee Schedule		9.65							Fee Schedule		7.8							Fee Schedule											9.65							Fee Schedule		7.8							Fee Schedule		
TRANDUCER	272	RC						Both			115.5	51.98	51.98	103.95	75.08							Fee Schedule		85.47							Fee Schedule																													103.95							Fee Schedule																																															
TRANEXAMIC ACID 1000MG/100ML PREMIX	250	RC	J0281	CPT				Both			75.6	34.02	1.92	68.04	49.14							Fee Schedule		55.94							Fee Schedule		1.92							Fee Schedule																				68.04							Fee Schedule																																															
TRANEXAMIC ACID 100MG/ML- 10ML VIAL	250	RC	J0281	CPT				Both			197.4	88.83	1.92	177.66	128.31							Fee Schedule		146.08							Fee Schedule		1.92							Fee Schedule																				177.66							Fee Schedule																																															
TRANSDERM SCOP 1MG/72 HR PATCH	250	RC	A9270	CPT				Both			80.85	36.38	0.01	72.77	0.01							Fee Schedule		59.83							Fee Schedule																													72.77							Fee Schedule																																															
TRANSDUCER COVER ANESTHESIA DAN-33812-WG	272	RC						Both			41	18.45	1.74	36.9	26.65							Fee Schedule		30.34							Fee Schedule																				1.87							Fee Schedule		36.9							Fee Schedule		2.15							Fee Schedule		1.74							Fee Schedule											2.15							Fee Schedule		1.74							Fee Schedule		
TRANSDUCER EXTENSION TUBING #50P172	272	RC						Both			28	12.6	1.74	25.2	18.2							Fee Schedule		20.72							Fee Schedule																				1.87							Fee Schedule		25.2							Fee Schedule		2.15							Fee Schedule		1.74							Fee Schedule											2.15							Fee Schedule		1.74							Fee Schedule		
TRANSDUCER KIT W/PRESSURE MONITOR SINGLE	272	RC						Both			25.2	11.34	11.34	22.68	16.38							Fee Schedule		18.65							Fee Schedule																													22.68							Fee Schedule																																															
TRANSDUCER W/PRESS MON. VAMP PXVP2260	272	RC						Both			341	153.45	153.45	306.9	221.65							Fee Schedule		252.34							Fee Schedule																													306.9							Fee Schedule																																															
TRANSFER SPIKE 415125	272	RC						Both			4.2	1.89	1.89	3.78	2.73							Fee Schedule		3.11							Fee Schedule																													3.78							Fee Schedule																																															
TRANSFERRIN CARBOHYDRATE-DEF 16985 1ML S	301	RC	82380	CPT				Both			78.75	35.44	8.2	70.88	8.2							Fee Schedule		10.25							Fee Schedule		9.5							Fee Schedule		9.22							Fee Schedule											70.88							Fee Schedule																				9.22							Fee Schedule																				
TRANSFERRIN SERUM	301	RC	84466	CPT				Both			167.5	75.38	11.35	150.75	11.35							Fee Schedule		14.18							Fee Schedule		13.14							Fee Schedule		12.76							Fee Schedule											150.75							Fee Schedule																				12.76							Fee Schedule																				
TRANSFUSION SERVICES	391	RC	36430	CPT				Both			636.3	286.34	30.61	572.67	51.63							Fee Schedule		470.86							Fee Schedule											30.61							Fee Schedule											572.67							Fee Schedule																				160							Case Rate																				
TRANSHEP/PERCUT CHOLANG	324	RC	47532	CPT				Both			345.45	155.45	8.57	318	302.69							Fee Schedule		255.63							Fee Schedule																				9.22							Fee Schedule		310.91							Fee Schedule		10.6							Fee Schedule		8.57							Fee Schedule		318							Per Diem		10.6							Fee Schedule		8.57							Fee Schedule		
POISONING AND TOXIC EFFECTS OF DRUGS WITH MCC					917	DRG		Inpatient			33788.99	15205.05	15205.05	15205.05							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period				4555.34	4555.34	4555.34	1 through 10						12189.76	12189.76	12189.76	1 through 10									0		No services provided during 15 month lookback period							0	Fee Schedule	No services provided during 15 month lookback period				5392.08	5392.08	5392.08	1 through 10	Fee Schedule								0		No services provided during 15 month lookback							0		No services provided during 15 month lookback period							0	Fee Schedule	No services provided during 15 month lookback period	
TRANSMYCRDL PAC KIT	271	RC						Both			219.45	98.75	98.75	197.51	142.64							Fee Schedule		162.39							Fee Schedule																													197.51							Fee Schedule																																															
TRANXENE 3.75 MG (CLORAZEPATE) TAB	250	RC	A9270	CPT				Both			4.2	1.89	0.01	3.78	0.01							Fee Schedule		3.11							Fee Schedule																													3.78							Fee Schedule																																															
TRAPEZE LOOP RIBBON (GYRUS)#140743	272	RC						Both			449.4	202.23	202.23	404.46	292.11							Fee Schedule		332.56							Fee Schedule																													404.46							Fee Schedule																																															
TRAPEZOID LITHOTRIPTER BASKET #M00510870	272	RC						Both			845	380.25	380.25	760.5	549.25							Fee Schedule		625.3							Fee Schedule																													760.5							Fee Schedule																																															
TRAPEZOID RX BASKET #M00510880	272	RC						Both			845	380.25	380.25	760.5	549.25							Fee Schedule		625.3							Fee Schedule																													760.5							Fee Schedule																																															
POISONING AND TOXIC EFFECTS OF DRUGS WITHOUT MCC					918	DRG		Inpatient			18586.38	8363.87	8363.87	8363.87							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period	
TRAVASOL 10% 500ML IVPB (AMINO ACID)	258	RC						Both			65.1	29.3	29.3	58.59	42.32							Fee Schedule		48.17							Fee Schedule																													58.59							Fee Schedule																																															
TRAVASOL 3.5 W\ELECT. 2B6613	258	RC						Both			70.35	31.66	31.66	63.32	45.73							Fee Schedule		52.06							Fee Schedule																													63.32							Fee Schedule																																															
TRAVASOL 8.5% 500 ML	258	RC						Both			204.75	92.14	92.14	184.28	133.09							Fee Schedule		151.52							Fee Schedule																													184.28							Fee Schedule																																															
TRAVATAN-Z 0.004% OPTHL SOLN- 2.5ML	250	RC	A9270	CPT				Both			386.4	173.88	0.01	347.76	0.01							Fee Schedule		285.94							Fee Schedule																													347.76							Fee Schedule																																															
TRAVEL ALLOWANCE HOMEBOUND	300	RC	P9603	CPT				Both			4.2	1.89	0.72	4.06	0.72							Fee Schedule		3.11							Fee Schedule											4.06							Fee Schedule											3.78							Fee Schedule																																															
TRAVEL ALLOWANCE NURSING HOME	300	RC	P9604	CPT				Both			13.65	6.14	4.06	12.29	7.2							Fee Schedule		10.1							Fee Schedule											4.06							Fee Schedule											12.29							Fee Schedule																																															
TRAZODONE  50MG (DESYREL) TABLET	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
TRAZODONE 100MG (DESYREL) TABLET	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
TRAZODONE DESYREL 4732 3ML SERUM	301	RC	80299	CPT				Both			252	113.4	13.42	226.8	13.42							Fee Schedule		18.64							Fee Schedule		19.2							Fee Schedule		18.64							Fee Schedule											226.8							Fee Schedule																				18.64							Fee Schedule																				
TREADMILL	482	RC	93017	CPT				Both			378	170.1	51.25	382	263							Per Diem		279.72							Fee Schedule											51.25							Fee Schedule											340.2							Fee Schedule																				382							Per Diem																				
TREADMILL W/OXIMETRY EXERCISE	482	RC	93017	CPT				Both			378	170.1	51.25	382	263							Per Diem		279.72							Fee Schedule											51.25							Fee Schedule											340.2							Fee Schedule																				382							Per Diem																				
TREATMENT RM ER	450	RC	99282	CPT				Outpatient			1050	472.5	54	1061	440							Case Rate									Other	No Additional Reimbursement 	142.78							Fee Schedule		54							Fee Schedule		142.78							Fee Schedule		945							Fee Schedule		166.29							Fee Schedule		300							Case Rate		1061							Case Rate		166.29							Fee Schedule		296							Case Rate		
TREATMENT ROOM BC AND BCTENN CARE	761	RC						Both			1050	472.5	472.5	945	682.5							Fee Schedule		777							Fee Schedule																													945							Fee Schedule																																															
TREATMENT/PROCEDURE ROOM	761	RC						Outpatient			525	236.25	236.25	472.5	341.25							Fee Schedule		388.5							Fee Schedule																													472.5							Fee Schedule																																															
TREMFYA 200MG/230ML NS  IVPB	636	RC	J1628	CPT				Both			52439.19	23597.64	67.81	47195.27		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	67.81							Fee Schedule		75.13							Fee Schedule																				47195.27							Fee Schedule																																															
TREMFYA IV SOLUTION 200MG/20ML VIAL	636	RC	J1628	CPT				Both			52439.19	23597.64	67.81	47195.27		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	67.81							Fee Schedule		75.13							Fee Schedule																				47195.27							Fee Schedule																																															
TRENGUARD 450 HYBRID BF124	270	RC						Both			240	108	108	216	156							Fee Schedule		177.6							Fee Schedule																													216							Fee Schedule																																															
TRENGUARD 600 CLASSIC PK BF126	270	RC	E0190	CPT				Both			419	188.55	35.61	377.1	35.61							Fee Schedule		310.06							Fee Schedule																				72.94							Fee Schedule		377.1							Fee Schedule		83.88							Fee Schedule		67.83							Fee Schedule											83.88							Fee Schedule		67.83							Fee Schedule		
TRENGUARD 600 HYBRID PK BF127	270	RC	E0190	CPT				Both			333	149.85	35.61	299.7	35.61							Fee Schedule		246.42							Fee Schedule																				72.94							Fee Schedule		299.7							Fee Schedule		83.88							Fee Schedule		67.83							Fee Schedule											83.88							Fee Schedule		67.83							Fee Schedule		
TRENGUARD CLASSIC 450 PROC. PACK #BF123	270	RC						Both			311	139.95	139.95	279.9	202.15							Fee Schedule		230.14							Fee Schedule																													279.9							Fee Schedule																																															
TRENGUARD HYBRID WEDGEBF134	270	RC	E0190	CPT				Both			262	117.9	35.61	235.8	35.61							Fee Schedule		193.88							Fee Schedule																													235.8							Fee Schedule																																															
TREPONEMA PALLIDUM AB PAR AGG 653	302	RC	86780	CPT				Both			24	10.8	10.8	21.6	11.76							Fee Schedule		14.71							Fee Schedule		13.64							Fee Schedule		13.24							Fee Schedule											21.6							Fee Schedule																				13.24							Fee Schedule																				
TRG T CELL ANTIGEN RECEPTOR BETA	300	RC	81340	CPT				Both			900	405	185.7	810	185.7							Fee Schedule		232.13							Fee Schedule		215.19							Fee Schedule		208.92							Fee Schedule											810							Fee Schedule																				208.92							Fee Schedule																				
TRG T CELL ANTIGEN RECEPTOR GAMMA	300	RC	81342	CPT				Both			860	387	179.11	774	179.11							Fee Schedule		223.88							Fee Schedule		207.55							Fee Schedule		201.5							Fee Schedule											774							Fee Schedule																				201.5							Fee Schedule																				
TRIAM/ HCTZ 37.5/25 MG (MAXZIDE) TABLET	250	RC	A9270	CPT				Both			6.3	2.84	0.01	15.23	0.01							Fee Schedule		4.66							Fee Schedule																				13.24							Fee Schedule		5.67							Fee Schedule		15.23							Fee Schedule		12.31							Fee Schedule											15.23							Fee Schedule		12.31							Fee Schedule		
TRIAMCINALONE (RT)10 MG	250	RC	J3301	CPT				Both			6.3	2.84	1.03	240.26	1.56							Fee Schedule		4.66							Fee Schedule		1.03							Fee Schedule		3.74							Fee Schedule		208.92							Fee Schedule		5.67							Fee Schedule		240.26							Fee Schedule		194.3							Fee Schedule											240.26							Fee Schedule		194.3							Fee Schedule		
TRIAMCINOLONE ACET 0.1% CREAM- 80 GM TUB	250	RC	A9270	CPT				Both			18.65	8.39	0.01	231.73	0.01							Fee Schedule		13.8							Fee Schedule																				201.5							Fee Schedule		16.79							Fee Schedule		231.73							Fee Schedule		187.4							Fee Schedule											231.73							Fee Schedule		187.4							Fee Schedule		
TRIAMCINOLONE ACET 0.1% CREAM-15GM	250	RC	A9270	CPT				Both			17.85	8.03	0.01	16.07	0.01							Fee Schedule		13.21							Fee Schedule																													16.07							Fee Schedule																																															
TRIAMCINOLONE ACET 40 MG/ML(KENALOG)INJ	636	RC	J3301	CPT				Both			34.65	15.59	0.93	31.19		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	25.64							Fee Schedule		1.03							Fee Schedule		3.74							Fee Schedule		1							Fee Schedule		31.19							Fee Schedule		1.15							Fee Schedule		0.93							Fee Schedule											1.15							Fee Schedule		0.93							Fee Schedule		
TRIAMCINOLONE ACETONIDE 0.025% CREAM-15G	250	RC	A9270	CPT				Both			6.14	2.76	0.01	5.53	0.01							Fee Schedule		4.54							Fee Schedule																													5.53							Fee Schedule																																															
TRIAMCINOLONE ACETONIDE 0.025% CREAM-80G	250	RC	A9270	CPT				Both			21	9.45	0.01	18.9	0.01							Fee Schedule		15.54							Fee Schedule																													18.9							Fee Schedule																																															
TRIAMCINOLONE ACETONIDE 0.1% DENTA PASTE	250	RC	A9270	CPT				Both			31.5	14.18	0.01	28.35	0.01							Fee Schedule		23.31							Fee Schedule																				1							Fee Schedule		28.35							Fee Schedule		1.15							Fee Schedule		0.93							Fee Schedule											1.15							Fee Schedule		0.93							Fee Schedule		
TRIAMCINOLONE ACETONIDE 0.1% OINTMENT-15	250	RC	A9270	CPT				Both			9.42	4.24	0.01	8.48	0.01							Fee Schedule		6.97							Fee Schedule																													8.48							Fee Schedule																																															
TRIAVIL 2/10 MG TAB	250	RC	A9270	CPT				Both			1.58	0.71	0.01	1.42	0.01							Fee Schedule		1.17							Fee Schedule																													1.42							Fee Schedule																																															
TRIAVIL 2/10 TABS	250	RC	A9270	CPT				Both			1.75	0.79	0.01	1.58	0.01							Fee Schedule		1.3							Fee Schedule																													1.58							Fee Schedule																																															
TRIAVIL 2/25 MG TAB	250	RC	A9270	CPT				Both			1.58	0.71	0.01	1.42	0.01							Fee Schedule		1.17							Fee Schedule																													1.42							Fee Schedule																																															
TRI-CHLOR	250	RC						Both			157.56	70.9	70.9	141.8	102.41							Fee Schedule		116.59							Fee Schedule																													141.8							Fee Schedule																																															
"TRICHOMONAS VAG RNA, QL TMA 19550"	306	RC	87661	CPT				Both			273	122.85	31.2	245.7	31.2							Fee Schedule		38.99							Fee Schedule		36.14							Fee Schedule		35.09							Fee Schedule											245.7							Fee Schedule																																															
"TRICHOMONAS VAG RNA, QL, MALES 90801"	306	RC	87661	CPT				Both			224	100.8	31.2	201.6	31.2							Fee Schedule		38.99							Fee Schedule		36.14							Fee Schedule		35.09							Fee Schedule											201.6							Fee Schedule																																															
TRICOR 145 MG TABLET	250	RC						Both			13.65	6.14	6.14	12.29	8.87							Fee Schedule		10.1							Fee Schedule																													12.29							Fee Schedule																																															
TRICOR 48MG TABLET	250	RC	A9270	CPT				Both			6.3	2.84	0.01	40.35	0.01							Fee Schedule		4.66							Fee Schedule																				35.09							Fee Schedule		5.67							Fee Schedule		40.35							Fee Schedule		32.63							Fee Schedule											40.35							Fee Schedule		32.63							Fee Schedule		
TRIDIL 50 MG/10 ML VIAL (NTG)	250	RC						Both			38.85	17.48	17.48	40.35	25.25							Fee Schedule		28.75							Fee Schedule																				35.09							Fee Schedule		34.97							Fee Schedule		40.35							Fee Schedule		32.63							Fee Schedule											40.35							Fee Schedule		32.63							Fee Schedule		
TRIFLUOPERAZINE 1 MG TABLET	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
TRIFLUOPERAZINE 5 MG TABLET UD	250	RC	A9270	CPT				Both			4.2	1.89	0.01	3.78	0.01							Fee Schedule		3.11							Fee Schedule																													3.78							Fee Schedule																																															
TRIGLYCERIDES	301	RC	84478	CPT				Both			40.95	18.43	5.1	36.86	5.1							Fee Schedule		6.38							Fee Schedule		5.91							Fee Schedule		5.74							Fee Schedule											36.86							Fee Schedule																				5.74							Fee Schedule																				
TRIGLYCERIDES PLEURAL FLD 17592	301	RC	84478	CPT				Both			12	5.4	5.1	10.8	5.1							Fee Schedule		6.38							Fee Schedule		5.91							Fee Schedule		5.74							Fee Schedule											10.8							Fee Schedule																				5.74							Fee Schedule																				
TRIHEXYPHENIDYL 2MG  (ARTANE) TABLET	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
TRILAFON 4 MG TAB	636	RC	Q0175	CPT				Both			1.58	0.71	0.71	6.6		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1.17							Fee Schedule																				5.74							Fee Schedule		1.42							Fee Schedule		6.6							Fee Schedule		5.34							Fee Schedule											6.6							Fee Schedule		5.34							Fee Schedule		
TRILEPTAL 150 MG (OXcarbazepine) TABLET	250	RC	A9270	CPT				Both			6.3	2.84	0.01	6.6	0.01							Fee Schedule		4.66							Fee Schedule																				5.74							Fee Schedule		5.67							Fee Schedule		6.6							Fee Schedule		5.34							Fee Schedule											6.6							Fee Schedule		5.34							Fee Schedule		
TRILEPTAL 300 MG (OXcarbazepine) TABLET	250	RC	A9270	CPT				Both			7.35	3.31	0.01	6.62	0.01							Fee Schedule		5.44							Fee Schedule																													6.62							Fee Schedule																																															
TRILISATE TAB 750MG	250	RC	A9270	CPT				Both			2.02	0.91	0.01	1.82	0.01							Fee Schedule		1.49							Fee Schedule																													1.82							Fee Schedule																																															
TRIMETHABENZAMIDE 100 MG RECTAL SUPP UD	250	RC	A9270	CPT				Both			4.2	1.89	0.01	3.78	0.01							Fee Schedule		3.11							Fee Schedule																													3.78							Fee Schedule																																															
TRIMETHABENZAMIDE 200 MG RECTAL SUPP	250	RC	A9270	CPT				Both			4.2	1.89	0.01	3.78	0.01							Fee Schedule		3.11							Fee Schedule																													3.78							Fee Schedule																																															
TRIMETHOBENZAMIDE 250 MG CAPSULE UD	636	RC	Q0173	CPT				Both			4.2	1.89	1.89	3.78		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	3.11							Fee Schedule																													3.78							Fee Schedule																																															
TRIMETHOPRIM 100 MG TABLET UD	250	RC	A9270	CPT				Both			4.2	1.89	0.01	3.78	0.01							Fee Schedule		3.11							Fee Schedule																													3.78							Fee Schedule																																															
TRIMOX:250 MG UD SUSP (AMOXICILLIN)	250	RC	A9270	CPT				Both			3.31	1.49	0.01	2.98	0.01							Fee Schedule		2.45							Fee Schedule																													2.98							Fee Schedule																																															
TRINALIN TABLETS	250	RC	A9270	CPT				Both			2.73	1.23	0.01	2.46	0.01							Fee Schedule		2.02							Fee Schedule																													2.46							Fee Schedule																																															
TRIPLE ANTIBIOTIC OINT PKTS	250	RC	A9270	CPT				Both			3.15	1.42	0.01	2.84	0.01							Fee Schedule		2.33							Fee Schedule																													2.84							Fee Schedule																																															
TRIPLE ANTIBIOTIC OINTMENT 30GM	250	RC	A9270	CPT				Both			17.89	8.05	0.01	16.1	0.01							Fee Schedule		13.24							Fee Schedule																													16.1							Fee Schedule																																															
TRIPLE DYE PINPOINT APPLICATORS	250	RC	A9270	CPT				Both			19.95	8.98	0.01	17.96	0.01							Fee Schedule		14.76							Fee Schedule																													17.96							Fee Schedule																																															
TRIPLE LUMEN KIT ARROW #CDC-45703-P1A	272	RC	A4300	CPT				Both			337	151.65	4.57	303.3	17.2							Fee Schedule		249.38							Fee Schedule											4.57							Fee Schedule											303.3							Fee Schedule																																															
TRIPLE LUMEN KIT SAFETY NEW CMPM7203LBB	272	RC	A4300	CPT				Both			366	164.7	4.57	329.4	17.2							Fee Schedule		270.84							Fee Schedule											4.57							Fee Schedule											329.4							Fee Schedule																																															
TRIPROLIDINE/PSUEDOEPHEDRINE TABLET UD	250	RC	A9270	CPT				Both			4.2	1.89	0.01	3.78	0.01							Fee Schedule		3.11							Fee Schedule																													3.78							Fee Schedule																																															
TROCAR (7/8) 578SD	272	RC						Both			317.1	142.7	142.7	285.39	206.12							Fee Schedule		234.65							Fee Schedule																													285.39							Fee Schedule																																															
TROCAR 5-12MM VERSAPORT	272	RC						Both			387.45	174.35	174.35	348.71	251.84							Fee Schedule		286.71							Fee Schedule																													348.71							Fee Schedule																																															
TROCAR 5MM SURGISPIKE	272	RC						Both			159.6	71.82	71.82	143.64	103.74							Fee Schedule		118.1							Fee Schedule																													143.64							Fee Schedule																																															
TROCAR BLADELESS 12MM X 150MM CTF71	272	RC						Both			75	33.75	33.75	67.5	48.75							Fee Schedule		55.5							Fee Schedule																													67.5							Fee Schedule																																															
TROCAR KIT	272	RC						Both			112.35	50.56	50.56	101.12	73.03							Fee Schedule		83.14							Fee Schedule																													101.12							Fee Schedule																																															
TROCAR THORACIC CATH 12FR 8888561027	272	RC						Both			36	16.2	16.2	32.4	23.4							Fee Schedule		26.64							Fee Schedule																													32.4							Fee Schedule																																															
TROCAR THORACIC CATH 16FR 8888561035	272	RC						Both			36	16.2	16.2	32.4	23.4							Fee Schedule		26.64							Fee Schedule																													32.4							Fee Schedule																																															
TROCAR THORACIC CATH 20FR 8888561043	272	RC						Both			36	16.2	16.2	32.4	23.4							Fee Schedule		26.64							Fee Schedule																													32.4							Fee Schedule																																															
TROCAR THORACIC CATH 24FR 8888561050	272	RC						Both			36	16.2	16.2	32.4	23.4							Fee Schedule		26.64							Fee Schedule																													32.4							Fee Schedule																																															
TROCAR THORACIC CATH 28FR 8888561068	272	RC						Both			36	16.2	16.2	32.4	23.4							Fee Schedule		26.64							Fee Schedule																													32.4							Fee Schedule																																															
TROCAR THORACIC CATH 32FR 8888561076	272	RC						Both			36	16.2	16.2	32.4	23.4							Fee Schedule		26.64							Fee Schedule																													32.4							Fee Schedule																																															
TROCAR TIP PASSING PIN 2.4MM 014395	272	RC						Both			410	184.5	184.5	369	266.5							Fee Schedule		303.4							Fee Schedule																													369							Fee Schedule																																															
TROCAR W/THREAD 5MM	272	RC						Both			306.6	137.97	137.97	275.94	199.29							Fee Schedule		226.88							Fee Schedule																													275.94							Fee Schedule																																															
TROCHANTER BELT UNI	274	RC	L2640	CPT				Both			31.5	14.18	14.18	397.76		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	23.31							Fee Schedule		397.76							Fee Schedule		295.82							Fee Schedule											28.35							Fee Schedule																																															
TROCHANTER BELT UNIVERSAL	274	RC	L2640	CPT				Both			24.1	10.85	10.85	397.76		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	17.83							Fee Schedule		397.76							Fee Schedule		295.82							Fee Schedule											21.69							Fee Schedule																																															
TROCHANTER BELT X-L	274	RC	L2640	CPT				Both			34.65	15.59	15.59	397.76		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	25.64							Fee Schedule		397.76							Fee Schedule		295.82							Fee Schedule											31.19							Fee Schedule																																															
TROPICAMIDE 1% OPTH SOLUTION-15ML	250	RC	A9270	CPT				Both			150.15	67.57	0.01	444.1	0.01							Fee Schedule		111.11							Fee Schedule																				386.17							Fee Schedule		135.14							Fee Schedule		444.1							Fee Schedule		359.14							Fee Schedule											444.1							Fee Schedule		359.14							Fee Schedule		
TROPONIN I HS	301	RC	84484	CPT				Both			201.6	90.72	8.98	444.1	8.98							Fee Schedule		12.47							Fee Schedule		12.84							Fee Schedule		12.47							Fee Schedule		386.17							Fee Schedule		181.44							Fee Schedule		444.1							Fee Schedule		359.14							Fee Schedule		12.47							Fee Schedule		444.1							Fee Schedule		359.14							Fee Schedule		
TROVAN:200 MG TABLET (TROVAFLOXACIN)	250	RC	A9270	CPT				Both			11.24	5.06	0.01	444.1	0.01							Fee Schedule		8.32							Fee Schedule																				386.17							Fee Schedule		10.12							Fee Schedule		444.1							Fee Schedule		359.14							Fee Schedule											444.1							Fee Schedule		359.14							Fee Schedule		
TROVAN:200 MG VIALS (ALATROFLOXACIN)	250	RC						Both			111.51	50.18	50.18	100.36	72.48							Fee Schedule		82.52							Fee Schedule																													100.36							Fee Schedule																																															
TROVAN:300 MG VIALS (ALATROFLOXACIN)	250	RC						Both			168.21	75.69	11.6	151.39	109.34							Fee Schedule		124.48							Fee Schedule																				12.47							Fee Schedule		151.39							Fee Schedule		14.34							Fee Schedule		11.6							Fee Schedule											14.34							Fee Schedule		11.6							Fee Schedule		
TRUMENBA MENINGOCOCCAL 0.5ML VACCINE	636	RC	90621	CPT				Both			151.2	68.04	68.04	136.08		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	111.89							Fee Schedule																													136.08							Fee Schedule																																															
TRUVADA 200MG/300MG TABLETS	250	RC	A9270	CPT				Both			211.05	94.97	0.01	189.95	0.01							Fee Schedule		156.18							Fee Schedule																													189.95							Fee Schedule																																															
TRYPANOSOMA CRUZI AB TOTAL 90827 SER 1ML	302	RC	86753	CPT				Both			115.5	51.98	11.01	103.95	11.01							Fee Schedule		13.76							Fee Schedule		12.76							Fee Schedule		12.39							Fee Schedule											103.95							Fee Schedule																				12.39							Fee Schedule																				
"TRYPANOSOMA CRUZI AB, RFX CONF 13230"	302	RC	86753	CPT				Both			249	112.05	11.01	224.1	11.01							Fee Schedule		13.76							Fee Schedule		12.76							Fee Schedule		12.39							Fee Schedule											224.1							Fee Schedule																				12.39							Fee Schedule																				
TRYPSIN SERUM 30329 1ML SERUM	301	RC	83519	CPT				Both			210	94.5	13.25	189	13.25							Fee Schedule		18.4							Fee Schedule		18.95							Fee Schedule		18.4							Fee Schedule											189							Fee Schedule																				18.4							Fee Schedule																				
TRYPTASE 34484 SERUM 1ML FROZEN	300	RC	83520	CPT				Both			80.85	36.38	11.52	72.77	12.43							Fee Schedule		17.27							Fee Schedule		17.79							Fee Schedule		17.27							Fee Schedule		12.39							Fee Schedule		72.77							Fee Schedule		14.25							Fee Schedule		11.52							Fee Schedule		17.27							Fee Schedule		14.25							Fee Schedule		11.52							Fee Schedule		
TSH	301	RC	84443	CPT				Both			175.35	78.91	11.52	157.82	14.94							Fee Schedule		18.67							Fee Schedule		17.3							Fee Schedule		16.8							Fee Schedule		12.39							Fee Schedule		157.82							Fee Schedule		14.25							Fee Schedule		11.52							Fee Schedule		16.8							Fee Schedule		14.25							Fee Schedule		11.52							Fee Schedule		
TTS DIALATOR GUN	272	RC						Both			112.35	50.56	17.11	101.12	73.03							Fee Schedule		83.14							Fee Schedule																				18.4							Fee Schedule		101.12							Fee Schedule		21.16							Fee Schedule		17.11							Fee Schedule											21.16							Fee Schedule		17.11							Fee Schedule		
TTS DIALATOR SYRINGE	270	RC						Both			112.35	50.56	16.06	101.12	73.03							Fee Schedule		83.14							Fee Schedule																				17.27							Fee Schedule		101.12							Fee Schedule		19.86							Fee Schedule		16.06							Fee Schedule											19.86							Fee Schedule		16.06							Fee Schedule		
TTS ESOPHAGEAL DILATOR	272	RC	C1726	CPT				Both			691.95	311.38	15.62	622.76	135.94							Fee Schedule		512.04							Fee Schedule																				16.8							Fee Schedule		622.76							Fee Schedule		19.32							Fee Schedule		15.62							Fee Schedule											19.32							Fee Schedule		15.62							Fee Schedule		
T-TUBE 8  FR. SU130-1224	272	RC	A4338	CPT				Both			26.25	11.81	9.73	23.63	9.73							Fee Schedule		19.43							Fee Schedule		15.85							Fee Schedule		12.16							Fee Schedule											23.63							Fee Schedule																																															
T-TUBE CATTELL 10 FR. #0100150(SENECA)	272	RC	A4338	CPT				Both			26.25	11.81	9.73	23.63	9.73							Fee Schedule		19.43							Fee Schedule		15.85							Fee Schedule		12.16							Fee Schedule											23.63							Fee Schedule																																															
T-TUBE CATTELL 12 FR. #SU130-123(SENECA)	272	RC	A4338	CPT				Both			1021	459.45	9.73	918.9	9.73							Fee Schedule		755.54							Fee Schedule		15.85							Fee Schedule		12.16							Fee Schedule											918.9							Fee Schedule																																															
T-TUBE CATTELL 14 FR. 3SU130-123(SENECA)	272	RC	A4338	CPT				Both			1021	459.45	9.73	918.9	9.73							Fee Schedule		755.54							Fee Schedule		15.85							Fee Schedule		12.16							Fee Schedule		15.39							Fee Schedule		918.9							Fee Schedule		17.7							Fee Schedule		14.31							Fee Schedule											17.7							Fee Schedule		14.31							Fee Schedule		
T-TUBE CATTELL 16 FR. #0100180(SENECA)	272	RC	A4338	CPT				Both			26.25	11.81	9.73	23.63	9.73							Fee Schedule		19.43							Fee Schedule		15.85							Fee Schedule		12.16							Fee Schedule		15.39							Fee Schedule		23.63							Fee Schedule		17.7							Fee Schedule		14.31							Fee Schedule											17.7							Fee Schedule		14.31							Fee Schedule		
T-TUBE CHOLANGIOGRAM	329	RC	47531	CPT				Both			315	141.75	14.31	318	101.02							Fee Schedule		233.1							Fee Schedule																				15.39							Fee Schedule		283.5							Fee Schedule		17.7							Fee Schedule		14.31							Fee Schedule		318							Per Diem		17.7							Fee Schedule		14.31							Fee Schedule		
TUBE TAMERS	271	RC						Both			45.15	20.32	14.31	40.64	29.35							Fee Schedule		33.41							Fee Schedule																				15.39							Fee Schedule		40.64							Fee Schedule		17.7							Fee Schedule		14.31							Fee Schedule											17.7							Fee Schedule		14.31							Fee Schedule		
TUBERCULIN 5 TU TEST (MANTOUX) PPD	300	RC	86580	CPT				Both			41.67	18.75	5.27	37.5	5.27							Fee Schedule		7.66							Fee Schedule											8.98							Fee Schedule		15.39							Fee Schedule		37.5							Fee Schedule		17.7							Fee Schedule		14.31							Fee Schedule											17.7							Fee Schedule		14.31							Fee Schedule		
TUBING 02 1115 HUDSON	271	RC						Both			1	0.45	0.45	0.9	0.65							Fee Schedule		0.74							Fee Schedule																													0.9							Fee Schedule																																															
TUBING EXTENSION SET ARGYLE 8884714200	272	RC						Both			19	8.55	8.55	17.1	12.35							Fee Schedule		14.06							Fee Schedule																													17.1							Fee Schedule																																															
TUCKS OINT- 30GM	250	RC	A9270	CPT				Both			21	9.45	0.01	18.9	0.01							Fee Schedule		15.54							Fee Schedule																													18.9							Fee Schedule																																															
TUM-E-VAC #2054 W/O CHARCOAL	271	RC						Both			95.55	43	43	86	62.11							Fee Schedule		70.71							Fee Schedule																													86							Fee Schedule																																															
TUMOR PROTEIN 53	312	RC	81352	CPT				Both			248.85	111.98	111.98	339.4	161.75							Fee Schedule		329.51							Fee Schedule		339.4							Fee Schedule		329.51							Fee Schedule											223.97							Fee Schedule																																															
TURP IRRIGATION SET BAXTER #2C4041	272	RC						Both			25	11.25	11.25	22.5	16.25							Fee Schedule		18.5							Fee Schedule																													22.5							Fee Schedule																																															
TUSSI ORGANIDIN : 0Z	250	RC	A9270	CPT				Both			10.24	4.61	0.01	9.22	0.01							Fee Schedule		7.58							Fee Schedule																													9.22							Fee Schedule																																															
TUSSI ORGANIDIN DM :0Z	250	RC	A9270	CPT				Both			2.07	0.93	0.01	378.94	0.01							Fee Schedule		1.53							Fee Schedule																				329.51							Fee Schedule		1.86							Fee Schedule		378.94							Fee Schedule		306.44							Fee Schedule											378.94							Fee Schedule		306.44							Fee Schedule		
TUSSIONEX 10/8MG SUSPENSION 5ML UD	250	RC	A9270	CPT				Both			8.4	3.78	0.01	7.56	0.01							Fee Schedule		6.22							Fee Schedule																													7.56							Fee Schedule																																															
TUTOPLAST 1.5X1.5 #68250 (IOP INC.)	278	RC	C2631	CPT				Both			833.7	375.17	375.17	750.33		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	616.94							Fee Schedule																													750.33							Fee Schedule																																															
TVT DEVICE  (J&J)	278	RC	C1771	CPT				Both			3780	1701	1701	3402		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	2797.2							Fee Schedule																													3402							Fee Schedule																																															
TVT DEVICE (AMS INC.) # 72403830	278	RC	C1771	CPT				Both			3258.15	1466.17	1466.17	2932.34		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	2411.03							Fee Schedule																													2932.34							Fee Schedule																																															
TVT INTRODUCER #810051	272	RC	C1771	CPT				Both			1874.25	843.41	87.91	1686.83	87.91							Fee Schedule		1386.95							Fee Schedule																													1686.83							Fee Schedule																																															
TVT MINI ARC #720046-01  ( AMS INC. )	278	RC	C1771	CPT				Both			4718.7	2123.42	2123.42	4246.83		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	3491.84							Fee Schedule																													4246.83							Fee Schedule																																															
TVT MINI ARC PRECISE 720191-01	278	RC	C1771	CPT				Both			5427.45	2442.35	2442.35	4884.71		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	4016.31							Fee Schedule																													4884.71							Fee Schedule																																															
TVT RIGID CATH GUIDE #810061	272	RC						Both			393.75	177.19	177.19	354.38	255.94							Fee Schedule		291.38							Fee Schedule																													354.38							Fee Schedule																																															
TWINRIX 20 MCG-720 ELU/ML VACCINE	636	RC	90636	CPT				Both			493.5	222.08	156.35	444.15		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	365.19							Fee Schedule											156.35							Fee Schedule											444.15							Fee Schedule																																															
TWIST DRILL 4.3	272	RC						Both			169.05	76.07	76.07	152.15	109.88							Fee Schedule		125.1							Fee Schedule																													152.15							Fee Schedule																																															
TWIST DRILL CROWE POINT 4.3	272	RC						Both			303.45	136.55	136.55	273.11	197.24							Fee Schedule		224.55							Fee Schedule																													273.11							Fee Schedule																																															
TWO CAL HN 1000ML RTH	250	RC	B4152	CPT				Both			52.5	23.63	0.17	47.25	0.17							Fee Schedule		38.85							Fee Schedule											0.69							Fee Schedule											47.25							Fee Schedule																																															
TWO FLEX 2-LAYER COMPRESS SYSTEM MSC6800	270	RC						Both			30	13.5	13.5	27	19.5							Fee Schedule		22.2							Fee Schedule																													27							Fee Schedule																																															
TWOCAL HN 8 OZ CAN	250	RC						Both			6.43	2.89	2.89	5.79	4.18							Fee Schedule		4.76							Fee Schedule																													5.79							Fee Schedule																																															
TYLENOL 160 MG/5ML CHILDREN SUSP-120ML	250	RC	A9270	CPT				Both			15.49	6.97	0.01	13.94	0.01							Fee Schedule		11.46							Fee Schedule																													13.94							Fee Schedule																																															
TYLENOL 650 MG EXTENDED RELEASE	250	RC						Both			1.58	0.71	0.71	1.42	1.03							Fee Schedule		1.17							Fee Schedule																													1.42							Fee Schedule																																															
TYLENOL ADULT LIQ.1000 MG/30 ML-80Z	250	RC	A9270	CPT				Both			17.33	7.8	0.01	15.6	0.01							Fee Schedule		12.82							Fee Schedule																													15.6							Fee Schedule																																															
TYLENOL CHEW TABLETS	250	RC	A9270	CPT				Both			4.2	1.89	0.01	3.78	0.01							Fee Schedule		3.11							Fee Schedule																													3.78							Fee Schedule																																															
TYLENOL CHILD LIQ 160 MG/5 ML (ER CHG)	250	RC						Both			3.15	1.42	1.42	2.84	2.05							Fee Schedule		2.33							Fee Schedule																													2.84							Fee Schedule																																															
TYLENOL CHILD LIQ 160 MG/5 ML (ER CHG.)	250	RC	A9270	CPT				Both			4.2	1.89	0.01	3.78	0.01							Fee Schedule		3.11							Fee Schedule																													3.78							Fee Schedule																																															
TYLENOL NO 2 TAB	250	RC	A9270	CPT				Both			1.58	0.71	0.01	1.42	0.01							Fee Schedule		1.17							Fee Schedule																													1.42							Fee Schedule																																															
TYLOX CAPSULES	250	RC	A9270	CPT				Both			7.35	3.31	0.01	6.62	0.01							Fee Schedule		5.44							Fee Schedule																													6.62							Fee Schedule																																															
TYPHOID VACCINE	636	RC	90691	CPT				Both			157.5	70.88	70.88	141.75		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	116.55							Fee Schedule											109.59							Fee Schedule											141.75							Fee Schedule																																															
U-BAG NEWBORN URINE COLLECTORS 7535	272	RC						Both			4.2	1.89	1.89	3.78	2.73							Fee Schedule		3.11							Fee Schedule																													3.78							Fee Schedule																																															
U-BAG PEDIATRIC URINE COLLECTORS 7531	272	RC						Both			9	4.05	4.05	8.1	5.85							Fee Schedule		6.66							Fee Schedule																													8.1							Fee Schedule																																															
UC DISP. ORTHOPEDIC SHORTS 2XLARGE	270	RC						Both			2.63	1.18	1.18	2.37	1.71							Fee Schedule		1.95							Fee Schedule																													2.37							Fee Schedule																																															
UC NASAL PACK W/GEL 7.5 RHINO	271	RC						Both			121.8	54.81	54.81	109.62	79.17							Fee Schedule		90.13							Fee Schedule																													109.62							Fee Schedule																																															
UC SECONDARY SET #2C7461	272	RC						Both			3.15	1.42	1.42	2.84	2.05							Fee Schedule		2.33							Fee Schedule																													2.84							Fee Schedule																																															
UCCLANCY FLEXIBLE REAMER SET 7203745	278	RC	C1713	CPT				Both			750	337.5	337.5	675		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	555							Fee Schedule																													675							Fee Schedule																																															
UGI AIR CONTRAST	320	RC	74246	CPT				Both			399	179.55	46.68	359.1	75.28							Fee Schedule		92.73							Fee Schedule											46.68							Fee Schedule											359.1							Fee Schedule																				318							Per Diem																				
UGI AIR W SMALL BOWEL	320	RC	74246	CPT				Both			535.5	240.98	46.68	481.95	75.28							Fee Schedule		92.73							Fee Schedule											46.68							Fee Schedule											481.95							Fee Schedule																				318							Per Diem																				
UGI SINGLE CONTRAST	320	RC	74240	CPT				Both			345.45	155.45	41.49	318	63.92							Fee Schedule		79.74							Fee Schedule											41.49							Fee Schedule											310.91							Fee Schedule																				318							Per Diem																				
UGI SINGLE CONTRAST W SMALL BOWEL FT	320	RC	74240	CPT				Both			141.75	63.79	41.49	318	63.92							Fee Schedule		79.74							Fee Schedule											41.49							Fee Schedule											127.58							Fee Schedule																				318							Per Diem																				
UHR UNIVERSAL HEAD	278	RC	C1776	CPT				Both			2444.4	1099.98	1099.98	2199.96		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1808.86							Fee Schedule																													2199.96							Fee Schedule																																															
ULCEREASE MOUTH RINSE	250	RC	A9270	CPT				Both			37.8	17.01	0.01	34.02	0.01							Fee Schedule		27.97							Fee Schedule																													34.02							Fee Schedule																																															
ULCEREASE MOUTHRINSE	250	RC	A9270	CPT				Both			15.69	7.06	0.01	14.12	0.01							Fee Schedule		11.61							Fee Schedule																													14.12							Fee Schedule																																															
ULESFIA 5% LOTION--8OZ	250	RC	A9270	CPT				Both			96.11	43.25	0.01	86.5	0.01							Fee Schedule		71.12							Fee Schedule																													86.5							Fee Schedule																																															
ULNA SHAFT 2.8 TRILOCK PLATE A-4857.11	278	RC	C1713	CPT				Both			3141	1413.45	1413.45	2826.9		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	2324.34							Fee Schedule																													2826.9							Fee Schedule																																															
ULNAR / GUTTER R AND L 2  ORTHO GLASS	274	RC	A4590	CPT				Both			222.6	100.17	24.09	200.34		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	164.72							Fee Schedule											24.09							Fee Schedule											200.34							Fee Schedule																																															
ULNAR / GUTTER R AND L 3  ORTHO GLASS	270	RC						Both			298.2	134.19	134.19	268.38	193.83							Fee Schedule		220.67							Fee Schedule																													268.38							Fee Schedule																																															
ULNAR / GUTTER R AND L 4  ORTHO GLASS	270	RC						Both			373.8	168.21	168.21	336.42	242.97							Fee Schedule		276.61							Fee Schedule																													336.42							Fee Schedule																																															
ULNAR / GUTTER R AND L 5  ORTHO GLASS	271	RC						Both			449.4	202.23	202.23	404.46	292.11							Fee Schedule		332.56							Fee Schedule																													404.46							Fee Schedule																																															
ULNAR NERVE PROTECTOR #NON081340	270	RC						Both			5	2.25	2.25	4.5	3.25							Fee Schedule		3.7							Fee Schedule																													4.5							Fee Schedule																																															
ULTRACLIP US BIOPSY BREAST CLIP  #863017	272	RC	A4648	CPT				Both			297	133.65	95.02	267.3	95.02							Fee Schedule		219.78							Fee Schedule																													267.3							Fee Schedule																																															
ULTRAFLEX ESOPHAGEAL STENT #M00513850	278	RC	C1874	CPT				Both			5177	2329.65	2329.65	4659.3		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	3830.98							Fee Schedule																													4659.3							Fee Schedule																																															
ULTRAFLEX ESOPHAGEAL STENT #M00513860	278	RC	C1874	CPT				Both			5177	2329.65	2329.65	4659.3		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	3830.98							Fee Schedule																													4659.3							Fee Schedule																																															
ULTRAPRO ADVANCED MESH 7.6X15CM UPA37615	278	RC	C1781	CPT				Both			277	124.65	124.65	249.3		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	204.98							Fee Schedule																													249.3							Fee Schedule																																															
ULTRASOUND BREAST LOCALIZATION 1ST	320	RC	19285	CPT				Both			2100	945	94.61	1890	94.61							Fee Schedule		1554							Fee Schedule																													1890							Fee Schedule																				318							Per Diem																				
ULTRASOUND BREAST LOCALIZATION ADDITION	320	RC	19286	CPT				Both			2100	945	47.23	1890	47.23							Fee Schedule		1554							Fee Schedule																													1890							Fee Schedule																				318							Per Diem																				
ULTRASOUND DISP. NEEDLE GUIDE 644-069	272	RC						Both			53	23.85	23.85	47.7	34.45							Fee Schedule		39.22							Fee Schedule																													47.7							Fee Schedule																																															
ULTRASOUND GEL PACKS STERILE 280NW	272	RC						Both			3	1.35	1.35	2.7	1.95							Fee Schedule		2.22							Fee Schedule																													2.7							Fee Schedule																																															
ULTRASOUND GUIDANCE FOR VASCULAR ACCESS	370	RC	76937	CPT				Both			65	29.25	11.95	58.5	13.97							Fee Schedule		17.86							Fee Schedule											11.95							Fee Schedule											58.5							Fee Schedule																																															
ULTRATAPE SUTURE COBRAID BLUE #72203897	272	RC						Both			195	87.75	87.75	175.5	126.75							Fee Schedule		144.3							Fee Schedule																													175.5							Fee Schedule																																															
ULTRATHANE SUPRAPUBIC SET 14FR G30405	272	RC						Both			390	175.5	175.5	351	253.5							Fee Schedule		288.6							Fee Schedule																													351							Fee Schedule																																															
"UMB.CATH.GRP.CHG. TAPE,GLOVE,BETSWB.CATH"	272	RC						Both			68.25	30.71	30.71	61.43	44.36							Fee Schedule		50.51							Fee Schedule																													61.43							Fee Schedule																																															
UMBILICAL CATH TRAY #8888160424 (SENECA)	272	RC						Both			165.9	74.66	74.66	149.31	107.84							Fee Schedule		122.77							Fee Schedule																													149.31							Fee Schedule																																															
UMBILICAL CATH TRAY 5FR.	272	RC						Both			79	35.55	35.55	71.1	51.35							Fee Schedule		58.46							Fee Schedule																													71.1							Fee Schedule																																															
UMBILICAL TAPE 30-409	272	RC						Both			3	1.35	1.35	2.7	1.95							Fee Schedule		2.22							Fee Schedule																													2.7							Fee Schedule																																															
UMBILICAL TAPE U11T *DISC.*	272	RC						Both			5.25	2.36	2.36	4.73	3.41							Fee Schedule		3.89							Fee Schedule																													4.73							Fee Schedule																																															
UMBRELLA ADAPTER STRYKER INTERFACER	272	RC						Both			23.1	10.4	10.4	20.79	15.02							Fee Schedule		17.09							Fee Schedule																													20.79							Fee Schedule																																															
UMBRELLA CEMENT INTRERFACER 206-521	272	RC						Both			93.45	42.05	42.05	84.11	60.74							Fee Schedule		69.15							Fee Schedule																													84.11							Fee Schedule																																															
COMPLICATIONS OF TREATMENT WITH MCC					919	DRG		Inpatient			40439.78	18197.9	18197.9	18197.9							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period							0		No services provided during 15 month lookback period				9664.88	9664.88	9664.88	1 through 10									0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period	
COMPLICATIONS OF TREATMENT WITH CC					920	DRG		Inpatient			26943.9	12124.76	12124.76	12124.76							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period. 				8173.48	8173.48	8173.48	1 through 10									0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period	
UNDERBUTTOCK DRAPE DYNJP6002	270	RC						Both			7.5	3.38	3.38	6.75	4.88							Fee Schedule		5.55							Fee Schedule																													6.75							Fee Schedule																																															
UNI. CEMENT PLUG	278	RC	C1776	CPT				Both			283.5	127.58	127.58	255.15		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	209.79							Fee Schedule																													255.15							Fee Schedule																																															
UNI. HEAD UH1	278	RC	C1776	CPT				Both			2283.75	1027.69	1027.69	2055.38		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1689.98							Fee Schedule																													2055.38							Fee Schedule																																															
UNIBOOT	271	RC						Both			15	6.75	6.75	13.5	9.75							Fee Schedule		11.1							Fee Schedule																													13.5							Fee Schedule																																															
UNILATERAL LEFT TAP	370	RC	64487	CPT				Both			375	168.75	87.26	337.5	87.26							Fee Schedule		277.5							Fee Schedule																													337.5							Fee Schedule																																															
UNIPHYL 200 MG TABS	250	RC	A9270	CPT				Both			1.58	0.71	0.01	1.42	0.01							Fee Schedule		1.17							Fee Schedule																													1.42							Fee Schedule																																															
UNIPHYL 400 MG TABLET UD	250	RC	A9270	CPT				Both			4.2	1.89	0.01	3.78	0.01							Fee Schedule		3.11							Fee Schedule																													3.78							Fee Schedule																																															
UNIPHYL 600 MG TABLET UD	250	RC	A9270	CPT				Both			4.2	1.89	0.01	3.78	0.01							Fee Schedule		3.11							Fee Schedule																													3.78							Fee Schedule																																															
UNIVENT BRONCHIAL BLOCKER 7.0 #1202630	272	RC						Both			472.5	212.63	212.63	425.25	307.13							Fee Schedule		349.65							Fee Schedule																													425.25							Fee Schedule																																															
UNIVENT BRONCHIAL BLOCKER 8.0 # 1202633	272	RC						Both			472.5	212.63	212.63	425.25	307.13							Fee Schedule		349.65							Fee Schedule																													425.25							Fee Schedule																																															
UNIVENT TUBE 7.0	272	RC						Both			241.5	108.68	108.68	217.35	156.98							Fee Schedule		178.71							Fee Schedule																													217.35							Fee Schedule																																															
UNIVERSAL FEEDING ADAPTER UFA-24-S	272	RC						Both			24.41	10.98	10.98	21.97	15.87							Fee Schedule		18.06							Fee Schedule																													21.97							Fee Schedule																																															
UNIVERSAL PACK 88761	270	RC						Both			70	31.5	31.5	63	45.5							Fee Schedule		51.8							Fee Schedule																													63							Fee Schedule																																															
UNLISTED MISC PATHOLOGY PROCEDURE	310	RC	89240	CPT				Both			85.05	38.27	38.27	76.55	55.28							Fee Schedule									Other	No Additional Reimbursement 																												76.55							Fee Schedule																																															
UNLISTED SURGICAL PATHOLOGY PROCEDURE	310	RC	88399	CPT				Both			85.05	38.27	38.27	76.55	55.28							Fee Schedule									Other	No Additional Reimbursement 																												76.55							Fee Schedule																																															
UNNA BOOT	271	RC						Both			15.23	6.85	6.85	13.71	9.9							Fee Schedule		11.27							Fee Schedule																													13.71							Fee Schedule																																															
UNNA BOOT #46-334	270	RC						Both			15	6.75	6.75	13.5	9.75							Fee Schedule		11.1							Fee Schedule																													13.5							Fee Schedule																																															
UNNA BOOT 1565 3	270	RC						Both			16.8	7.56	7.56	15.12	10.92							Fee Schedule		12.43							Fee Schedule																													15.12							Fee Schedule																																															
UNNA BOOT PT 1565-4	271	RC						Both			20.34	9.15	9.15	18.31	13.22							Fee Schedule		15.05							Fee Schedule																													18.31							Fee Schedule																																															
"OTHER INJURY, POISONING AND TOXIC EFFECT DIAGNOSES WITHOUT M"					923	DRG		Inpatient			7818.9	3518.51	3518.51	3518.51							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period	
UPSYLON Y-MESH M0068318200	272	RC	C1781	CPT				Both			2895	1302.75	478.48	2605.5	478.48							Fee Schedule		2142.3							Fee Schedule																													2605.5							Fee Schedule																																															
URANIUM 34698 URINE	300	RC	83018	CPT				Both			78.75	35.44	19.53	70.88	19.53							Fee Schedule		24.41							Fee Schedule		22.62							Fee Schedule		21.96							Fee Schedule											70.88							Fee Schedule																				21.96							Fee Schedule																				
URECHOLINE 5 MG/ML INJECTION	636	RC	J0520	CPT				Both			14.71	6.62	6.62	13.24		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	10.89							Fee Schedule																													13.24							Fee Schedule																																															
URETERAL BOUGIE	272	RC						Both			147	66.15	66.15	132.3	95.55							Fee Schedule		108.78							Fee Schedule																													132.3							Fee Schedule																																															
URETERAL CATHETER 10F COOK G17013	272	RC	C1758	CPT				Both			121	54.45	20.42	108.9	26.42							Fee Schedule		89.54							Fee Schedule																				21.96							Fee Schedule		108.9							Fee Schedule		25.25							Fee Schedule		20.42							Fee Schedule											25.25							Fee Schedule		20.42							Fee Schedule		
URETERAL CATHETER OPEN M0064002011	272	RC						Both			32	14.4	14.4	28.8	20.8							Fee Schedule		23.68							Fee Schedule																													28.8							Fee Schedule																																															
URETERAL CONE TIP	272	RC						Both			147	66.15	66.15	132.3	95.55							Fee Schedule		108.78							Fee Schedule																													132.3							Fee Schedule																																															
URETERAL FILIFORMS	272	RC						Both			19.95	8.98	8.98	17.96	12.97							Fee Schedule		14.76							Fee Schedule																													17.96							Fee Schedule																																															
URETERAL ILLUM CATH SET W/ PLUGS 084120	272	RC	C1729	CPT				Both			534.45	240.5	13.87	481.01	13.87							Fee Schedule		395.49							Fee Schedule																													481.01							Fee Schedule																																															
URETERAL STENT	278	RC	C2617	CPT				Both			231	103.95	103.95	207.9		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	170.94							Fee Schedule																													207.9							Fee Schedule																																															
URETERAL WHISTLE 8FR	272	RC						Both			147	66.15	66.15	132.3	95.55							Fee Schedule		108.78							Fee Schedule																													132.3							Fee Schedule																																															
URETHRAL CATH 16FR LATEX FREE DYND10724	272	RC						Both			2	0.9	0.9	1.8	1.3							Fee Schedule		1.48							Fee Schedule																													1.8							Fee Schedule																																															
URETHRAL CATH TRAY	272	RC						Both			11.55	5.2	5.2	10.4	7.51							Fee Schedule		8.55							Fee Schedule																													10.4							Fee Schedule																																															
URETHRAL DILATOR SET S-CURVE 8FR G32789	272	RC						Both			698	314.1	314.1	628.2	453.7							Fee Schedule		516.52							Fee Schedule																													628.2							Fee Schedule																																															
URETHRAL TRAY #DYND10402	272	RC	A4353	CPT				Both			12	5.4	5.4	10.8	6.3							Fee Schedule		8.88							Fee Schedule		10.29							Fee Schedule		7.88							Fee Schedule											10.8							Fee Schedule																																															
URETHRAL TRAY 75010 (HOME HEALTH)	272	RC						Both			6.72	3.02	3.02	6.05	4.37							Fee Schedule		4.97							Fee Schedule																													6.05							Fee Schedule																																															
URIC ACID	301	RC	84550	CPT				Both			30.45	13.7	4.02	27.41	4.02							Fee Schedule		5.02							Fee Schedule		4.66							Fee Schedule		4.52							Fee Schedule											27.41							Fee Schedule																				4.52							Fee Schedule																				
URIC ACID 11217 RANDOM UA RT	301	RC	84560	CPT				Both			28.35	12.76	4.22	25.52	4.22							Fee Schedule		5.27							Fee Schedule		5.23							Fee Schedule		5.08							Fee Schedule		9.99							Fee Schedule		25.52							Fee Schedule		11.49							Fee Schedule		9.29							Fee Schedule		5.08							Fee Schedule		11.49							Fee Schedule		9.29							Fee Schedule		
URIC ACID URINE 24 HR  907	301	RC	84560	CPT				Both			28.35	12.76	4.22	25.52	4.22							Fee Schedule		5.27							Fee Schedule		5.23							Fee Schedule		5.08							Fee Schedule											25.52							Fee Schedule																				5.08							Fee Schedule																				
"URIC ACID, SYNOVIAL FLD 4403"	301	RC	84560	CPT				Both			21	9.45	4.2	18.9	4.22							Fee Schedule		5.27							Fee Schedule		5.23							Fee Schedule		5.08							Fee Schedule		4.52							Fee Schedule		18.9							Fee Schedule		5.2							Fee Schedule		4.2							Fee Schedule		5.08							Fee Schedule		5.2							Fee Schedule		4.2							Fee Schedule		
URINAL #DYND80235S	271	RC	E0325	CPT				Both			1	0.45	0.45	11.34	6.02							Fee Schedule		0.74							Fee Schedule		11.34							Fee Schedule											5.08							Fee Schedule		0.9							Fee Schedule		5.84							Fee Schedule		4.72							Fee Schedule											5.84							Fee Schedule		4.72							Fee Schedule		
URINALYSIS  W O MICRO	307	RC	81003	CPT				Both			43.05	19.37	1.99	38.75	1.99							Fee Schedule		2.49							Fee Schedule		2.32							Fee Schedule		2.25							Fee Schedule		5.08							Fee Schedule		38.75							Fee Schedule		5.84							Fee Schedule		4.72							Fee Schedule		2.25							Fee Schedule		5.84							Fee Schedule		4.72							Fee Schedule		
URINALYSIS (UNSPUN)	307	RC	81000	CPT				Both			9.45	4.25	2.89	8.51	2.89							Fee Schedule		4.02							Fee Schedule		4.14							Fee Schedule		4.02							Fee Schedule		5.08							Fee Schedule		8.51							Fee Schedule		5.84							Fee Schedule		4.72							Fee Schedule		4.02							Fee Schedule		5.84							Fee Schedule		4.72							Fee Schedule		
URINALYSIS DIP STICK	307	RC	81002	CPT				Both			17.85	8.03	2.51	16.07	2.51							Fee Schedule		3.48							Fee Schedule		3.58							Fee Schedule		3.48							Fee Schedule		11.01							Fee Schedule		16.07							Fee Schedule		12.66							Fee Schedule		10.24							Fee Schedule		3.48							Fee Schedule		12.66							Fee Schedule		10.24							Fee Schedule		
URINALYSIS W MICRO	307	RC	81001	CPT				Both			68.25	30.71	2.09	61.43	2.82							Fee Schedule		3.52							Fee Schedule		3.27							Fee Schedule		3.17							Fee Schedule		2.25							Fee Schedule		61.43							Fee Schedule		2.59							Fee Schedule		2.09							Fee Schedule		3.17							Fee Schedule		2.59							Fee Schedule		2.09							Fee Schedule		
URINALYSIS/ ER W/MICRO(BC*TS)	307	RC	81001	CPT				Both			51.45	23.15	2.82	46.31	2.82							Fee Schedule		3.52							Fee Schedule		3.27							Fee Schedule		3.17							Fee Schedule		4.02							Fee Schedule		46.31							Fee Schedule		4.62							Fee Schedule		3.74							Fee Schedule		3.17							Fee Schedule		4.62							Fee Schedule		3.74							Fee Schedule		
URINARY DRAIN BAG 2000ML 154002 (BD MED)	272	RC						Both			12	5.4	3.24	10.8	7.8							Fee Schedule		8.88							Fee Schedule																				3.48							Fee Schedule		10.8							Fee Schedule		4							Fee Schedule		3.24							Fee Schedule											4							Fee Schedule		3.24							Fee Schedule		
URINARY DRAIN BAG 4000ML 153509 (BD MED)	272	RC						Both			11	4.95	2.95	9.9	7.15							Fee Schedule		8.14							Fee Schedule																				3.17							Fee Schedule		9.9							Fee Schedule		3.65							Fee Schedule		2.95							Fee Schedule											3.65							Fee Schedule		2.95							Fee Schedule		
URINARY DRAINAGE BAG	272	RC						Both			22.05	9.92	2.95	19.85	14.33							Fee Schedule		16.32							Fee Schedule																				3.17							Fee Schedule		19.85							Fee Schedule		3.65							Fee Schedule		2.95							Fee Schedule											3.65							Fee Schedule		2.95							Fee Schedule		
URINARY DRAINAGE BAG #154002	272	RC	A4357	CPT				Both			6	2.7	2.7	12.11	7.43							Fee Schedule		4.44							Fee Schedule		12.11							Fee Schedule		9.29							Fee Schedule											5.4							Fee Schedule																																															
URINARY DRAINAGE BAG 4000ML 6261	272	RC						Both			26	11.7	11.7	23.4	16.9							Fee Schedule		19.24							Fee Schedule																													23.4							Fee Schedule																																															
URINARY DRAINAGE BAG 6251	272	RC	A4358	CPT				Both			23.6	10.62	5.07	21.24	5.07							Fee Schedule		17.46							Fee Schedule		8.28							Fee Schedule		6.34							Fee Schedule											21.24							Fee Schedule																																															
URINARY LEG BAG	272	RC						Both			10.5	4.73	4.73	13.52	6.83							Fee Schedule		7.77							Fee Schedule																				11.76							Fee Schedule		9.45							Fee Schedule		13.52							Fee Schedule		10.94							Fee Schedule											13.52							Fee Schedule		10.94							Fee Schedule		
URINARY LEG BAG 900ML URO5458	272	RC	A4358	CPT				Both			10	4.5	4.5	9	5.07							Fee Schedule		7.4							Fee Schedule		8.28							Fee Schedule		6.34							Fee Schedule											9							Fee Schedule																																															
URINARY LEG BAG 950ML 150832 (BD MED)	272	RC						Both			8	3.6	3.6	9.25	5.2							Fee Schedule		5.92							Fee Schedule																				8.04							Fee Schedule		7.2							Fee Schedule		9.25							Fee Schedule		7.48							Fee Schedule											9.25							Fee Schedule		7.48							Fee Schedule		
URINARY LEG BAG W/ STRAPS 600ML URO5454	272	RC	A4358	CPT				Both			10	4.5	4.5	9	5.07							Fee Schedule		7.4							Fee Schedule		8.28							Fee Schedule		6.34							Fee Schedule											9							Fee Schedule																																															
SIGNS AND SYMPTOMS WITH MCC					947	DRG		Inpatient			62365.21	28064.34	28064.34	28064.34							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0	Fee Schedule	No services provided during 15 month lookback period							0	Fee Schedule	No services provided during 15 month lookback period							0		No services provided during 15 month lookback							0		No services provided during 15 month lookback period							0	Fee Schedule	No services provided during 15 month lookback period	
URINE CO2 BICARBONATE 3210	301	RC	82374	CPT				Both			142.8	64.26	4.34	128.52	4.34							Fee Schedule		5.43							Fee Schedule		5.03							Fee Schedule		4.88							Fee Schedule											128.52							Fee Schedule																				4.88							Fee Schedule																				
URINE COPPER 365   25ML OF 24 HR URINE	301	RC	82525	CPT				Both			52.5	23.63	7.48	47.25	11.03							Fee Schedule		13.79							Fee Schedule		12.78							Fee Schedule		12.41							Fee Schedule		8.04							Fee Schedule		47.25							Fee Schedule		9.25							Fee Schedule		7.48							Fee Schedule		12.41							Fee Schedule		9.25							Fee Schedule		7.48							Fee Schedule		
URINE CS2 IODINE AZIDE 16601	301	RC	80299	CPT				Both			306.6	137.97	13.42	275.94	13.42							Fee Schedule		18.64							Fee Schedule		19.2							Fee Schedule		18.64							Fee Schedule											275.94							Fee Schedule																				18.64							Fee Schedule																				
URINE DRAINAGE BAG  ADD-A-FOLEY 3515	272	RC						Both			39	17.55	4.54	35.1	25.35							Fee Schedule		28.86							Fee Schedule																				4.88							Fee Schedule		35.1							Fee Schedule		5.61							Fee Schedule		4.54							Fee Schedule											5.61							Fee Schedule		4.54							Fee Schedule		
URINE FOR EOSINOPHILS 8559	301	RC	85999	CPT				Both			44.1	19.85	11.54	39.69	28.67							Fee Schedule									Other	No Additional Reimbursement 																			12.41							Fee Schedule		39.69							Fee Schedule		14.27							Fee Schedule		11.54							Fee Schedule											14.27							Fee Schedule		11.54							Fee Schedule		
URINE METER 7000LL	272	RC						Both			39.9	17.96	17.34	35.91	25.94							Fee Schedule		29.53							Fee Schedule																				18.64							Fee Schedule		35.91							Fee Schedule		21.44							Fee Schedule		17.34							Fee Schedule											21.44							Fee Schedule		17.34							Fee Schedule		
URINE ORGANIC ACID PANEL 90561 13 ML FRZ	301	RC	83918	CPT				Both			420	189	16.99	378	16.99							Fee Schedule		23.6							Fee Schedule		24.31							Fee Schedule		23.6							Fee Schedule											378							Fee Schedule																				23.6							Fee Schedule																				
URINE PREGNANCY	307	RC	81025	CPT				Both			135.45	60.95	6.2	121.91	6.2							Fee Schedule		8.61							Fee Schedule		8.87							Fee Schedule		8.61							Fee Schedule											121.91							Fee Schedule																				8.61							Fee Schedule																				
URINE REDUCING SUBSTANCES  1688  8ML URI	301	RC	81005	CPT				Both			44.1	19.85	1.92	39.69	1.92							Fee Schedule		2.41							Fee Schedule		2.24							Fee Schedule		2.17							Fee Schedule											39.69							Fee Schedule																				2.17							Fee Schedule																				
URINE ZINC 946   7ML /24 HR URINE SP HAN	301	RC	84630	CPT				Both			63	28.35	10.12	56.7	10.12							Fee Schedule		12.65							Fee Schedule		11.73							Fee Schedule		11.39							Fee Schedule		23.6							Fee Schedule		56.7							Fee Schedule		27.14							Fee Schedule		21.95							Fee Schedule		11.39							Fee Schedule		27.14							Fee Schedule		21.95							Fee Schedule		
UROBILINOGEN	301	RC	84580	CPT				Both			124.95	56.23	7.26	112.46	7.26							Fee Schedule		9.55							Fee Schedule		9.84							Fee Schedule		9.55							Fee Schedule		8.61							Fee Schedule		112.46							Fee Schedule		9.9							Fee Schedule		8.01							Fee Schedule		9.55							Fee Schedule		9.9							Fee Schedule		8.01							Fee Schedule		
UROCATCHER DRAIN BAG #DSC-UC32A	272	RC						Both			53	23.85	2.02	47.7	34.45							Fee Schedule		39.22							Fee Schedule																				2.17							Fee Schedule		47.7							Fee Schedule		2.5							Fee Schedule		2.02							Fee Schedule											2.5							Fee Schedule		2.02							Fee Schedule		
UROLIFT HANDLE W/ 1 IMPLANT #UL2-CHK	278	RC	L8699	CPT				Both			3525	1586.25	10.59	3172.5		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	2608.5							Fee Schedule																				11.39							Fee Schedule		3172.5							Fee Schedule		13.1							Fee Schedule		10.59							Fee Schedule											13.1							Fee Schedule		10.59							Fee Schedule		
UROLIFT IMPL. DIFF. ANATOMY # UL2ATC-C	278	RC	L8699	CPT				Both			3525	1586.25	8.88	3172.5		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	2608.5							Fee Schedule																				9.55							Fee Schedule		3172.5							Fee Schedule		10.98							Fee Schedule		8.88							Fee Schedule											10.98							Fee Schedule		8.88							Fee Schedule		
UROLIFT REGULAR IMPLANT # UL2-C	278	RC	L8699	CPT				Both			3525	1586.25	1586.25	3172.5		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	2608.5							Fee Schedule																													3172.5							Fee Schedule																																															
UROMAX BALLOON DILAT. CATH. M0062251000	272	RC						Both			725	326.25	326.25	652.5	471.25							Fee Schedule		536.5							Fee Schedule																													652.5							Fee Schedule																																															
UROMAX KIT BALLOON CATHETER 225-137	272	RC	C1726	CPT				Both			870.45	391.7	135.94	783.41	135.94							Fee Schedule		644.13							Fee Schedule																													783.41							Fee Schedule																																															
UROPORPHYRINOGEN III 30521 SYNTHASE RBC	301	RC	82657	CPT				Both			720	324	16.05	648	16.05							Fee Schedule		22.17							Fee Schedule		22.84							Fee Schedule		22.17							Fee Schedule											648							Fee Schedule																				22.17							Fee Schedule																				
UROSTOMY BAGS EACH	271	RC						Both			14.7	6.62	6.62	13.23	9.56							Fee Schedule		10.88							Fee Schedule																													13.23							Fee Schedule																																															
UROSTOMY DRAIN POUCH (CONVATEC #401534	270	RC	A5073	CPT				Both			17.85	8.03	2.72	16.07	2.72							Fee Schedule		13.21							Fee Schedule		4.43							Fee Schedule		3.4							Fee Schedule											16.07							Fee Schedule																																															
UROSTOMY EXTENSION TUBING #9803	270	RC	A4335	CPT				Both			24.15	10.87	10.87	25.5	15.7							Fee Schedule		17.87							Fee Schedule																				22.17							Fee Schedule		21.74							Fee Schedule		25.5							Fee Schedule		20.62							Fee Schedule											25.5							Fee Schedule		20.62							Fee Schedule		
UROSTOMY POUCH 1 3/4 #18402	274	RC	A4379	CPT				Both			2.89	1.3	1.3	22.04		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	2.14							Fee Schedule		22.04							Fee Schedule																				2.6							Fee Schedule																																															
UROSTOMY RING BARRIER #7805	274	RC	A4385	CPT				Both			7	3.15	3.15	7.48		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	5.18							Fee Schedule		7.48							Fee Schedule											4.3							Fee Schedule		6.3							Fee Schedule		4.95							Fee Schedule		4							Fee Schedule											4.95							Fee Schedule		4							Fee Schedule		
UROSTOMY SEALS (CONVATEC #839002)	270	RC	A5121	CPT				Both			7.35	3.31	3.31	10.94	6.71							Fee Schedule		5.44							Fee Schedule		10.94							Fee Schedule		8.39							Fee Schedule											6.62							Fee Schedule																																															
UROVAC BLADDER EVACUATOR M0067301251	272	RC						Both			64	28.8	19.9	57.6	41.6							Fee Schedule		47.36							Fee Schedule																				21.4							Fee Schedule		57.6							Fee Schedule		24.61							Fee Schedule		19.9							Fee Schedule											24.61							Fee Schedule		19.9							Fee Schedule		
URSODIOL 300MG CAPSULE	250	RC	A9270	CPT				Both			6.3	2.84	0.01	8.35	0.01							Fee Schedule		4.66							Fee Schedule																				7.26							Fee Schedule		5.67							Fee Schedule		8.35							Fee Schedule		6.75							Fee Schedule											8.35							Fee Schedule		6.75							Fee Schedule		
US AAA SCREENING	402	RC	76706	CPT				Both			525	236.25	9.88	530	325							Per Diem		78.45							Fee Schedule											48.97							Fee Schedule		10.62							Fee Schedule		472.5							Fee Schedule		12.21							Fee Schedule		9.88							Fee Schedule		530							Case Rate		12.21							Fee Schedule		9.88							Fee Schedule		
US ABDOMINAL COMPLETE	402	RC	76700	CPT				Both			525	236.25	55.69	530	325							Per Diem		73.9							Fee Schedule											55.69							Fee Schedule											472.5							Fee Schedule																				530							Case Rate																				
US ABDOMINAL LIMITED	402	RC	76705	CPT				Both			525	236.25	40.08	530	325							Per Diem		56.04							Fee Schedule											40.08							Fee Schedule											472.5							Fee Schedule																				530							Case Rate																				
US ABDOMINAL W KINEVAC	402	RC	76700	CPT				Both			525	236.25	55.69	530	325							Per Diem		73.9							Fee Schedule											55.69							Fee Schedule											472.5							Fee Schedule																				530							Case Rate																				
US AMNIOCENTESIS	402	RC	76946	CPT				Both			525	236.25	11.88	530	325							Per Diem		11.88							Fee Schedule											43.3							Fee Schedule											472.5							Fee Schedule																				530							Case Rate																				
US BIOPHYSICAL PROFILE	402	RC	76818	CPT				Both			525	236.25	45.83	530	325							Per Diem		61.43							Fee Schedule											45.83							Fee Schedule											472.5							Fee Schedule																				530							Case Rate																				
US BREAST BX ADDITIONAL	320	RC	19084	CPT				Both			2100	945	86.21	1890	86.21							Fee Schedule		1554							Fee Schedule																													1890							Fee Schedule																				318							Per Diem																				
US BREAST COMPLETE	402	RC	76641	CPT				Both			525	236.25	52.32	530	325							Per Diem		64.16							Fee Schedule											52.32							Fee Schedule											472.5							Fee Schedule																				530							Case Rate																				
US BREAST LIMITED	402	RC	76642	CPT				Both			525	236.25	40.06	530	325							Per Diem		48.57							Fee Schedule											40.06							Fee Schedule											472.5							Fee Schedule																				530							Case Rate																				
US CALLBACK	402	RC						Both			195.3	87.89	87.89	530	325							Per Diem		144.52							Fee Schedule																													175.77							Fee Schedule																				530							Case Rate																				
US CHEST	402	RC	76604	CPT				Both			525	236.25	36.83	530	325							Per Diem		56.36							Fee Schedule											36.83							Fee Schedule											472.5							Fee Schedule																				530							Case Rate																				
US EXT LT ECHO N/VAS	402	RC	76882	CPT				Both			525	236.25	7.72	530	325							Per Diem		29.74							Fee Schedule											7.72							Fee Schedule											472.5							Fee Schedule																				530							Case Rate																				
US EXT RT ECHO N/VAS	402	RC	76882	CPT				Both			525	236.25	7.72	530	325							Per Diem		29.74							Fee Schedule											7.72							Fee Schedule											472.5							Fee Schedule																				530							Case Rate																				
US FETAL 3D 4D	483	RC	76376	CPT				Both			661.5	297.68	11.88	668	420							Per Diem		11.88							Fee Schedule											94.38							Fee Schedule											595.35							Fee Schedule																				668							Per Diem																				
US FETAL DOPPLER	483	RC	76827	CPT				Both			2205	992.25	41.75	1984.5	420							Per Diem		41.75							Fee Schedule											49.04							Fee Schedule											1984.5							Fee Schedule																				668							Per Diem																				
US FETAL ECHO	483	RC	76825	CPT				Both			2205	992.25	55.69	1984.5	420							Per Diem		175.4							Fee Schedule											55.69							Fee Schedule											1984.5							Fee Schedule																				668							Per Diem																				
US FETAL STUDY FUP	402	RC	76816	CPT				Both			525	236.25	31.36	530	325							Per Diem		64.48							Fee Schedule											31.36							Fee Schedule											472.5							Fee Schedule																				530							Case Rate																				
US FETAL STUDY LTD	402	RC	76815	CPT				Both			525	236.25	40.08	530	325							Per Diem		46.95							Fee Schedule											40.08							Fee Schedule											472.5							Fee Schedule																				530							Case Rate																				
US FTL GTR 14 WKS ADD	402	RC	76810	CPT				Both			525	236.25	38.97	530	325							Per Diem		38.97							Fee Schedule											118.55							Fee Schedule											472.5							Fee Schedule																				530							Case Rate																				
US FTL GTR 14 WKS COMP	402	RC	76805	CPT				Both			525	236.25	59.47	530	325							Per Diem		82.34							Fee Schedule											59.47							Fee Schedule											472.5							Fee Schedule																				530							Case Rate																				
US FTL LESS 14 WKS ADD	402	RC	76802	CPT				Both			525	236.25	19.81	530	325							Per Diem		19.81							Fee Schedule											20.87							Fee Schedule											472.5							Fee Schedule																				530							Case Rate																				
US FTL LESS 14 WKS COMP	402	RC	76801	CPT				Both			525	236.25	29.75	530	325							Per Diem		66.11							Fee Schedule											29.75							Fee Schedule											472.5							Fee Schedule																				530							Case Rate																				
US FTL TRANSVAG	402	RC	76817	CPT				Both			525	236.25	41.51	530	325							Per Diem		53.44							Fee Schedule											41.51							Fee Schedule											472.5							Fee Schedule																				530							Case Rate																				
US GUIDANCE FOR VASCULAR ACCESS			76937	CPT				Both			525	236.25	11.95	472.5	13.97							Fee Schedule		17.86							Fee Schedule											11.95							Fee Schedule											472.5							Fee Schedule																																															
US GUIDANCE NEEDLE	402	RC	76942	CPT				Both			525	236.25	22.59	530	325							Per Diem		22.59							Fee Schedule											43.3							Fee Schedule											472.5							Fee Schedule																				530							Case Rate																				
US GUIDANCE NEEDLE	402	RC	76942	CPT				Both			525	236.25	22.59	530	325							Per Diem		22.59							Fee Schedule											43.3							Fee Schedule											472.5							Fee Schedule																				530							Case Rate																				
US GUIDED ABS DRAIN	320	RC	75989	CPT				Both			315	141.75	57.34	318	220							Fee Schedule		57.34							Fee Schedule											89.02							Fee Schedule											283.5							Fee Schedule																				318							Per Diem																				
US HYST WWO CLR FLW	402	RC	76831	CPT				Both			525	236.25	42.72	530	325							Per Diem		74.87							Fee Schedule											42.72							Fee Schedule											472.5							Fee Schedule																				530							Case Rate																				
US INF HIPS WITH PHYS MANIPULATION	402	RC	76882	CPT				Both			525	236.25	7.72	530	325							Per Diem		29.74							Fee Schedule											7.72							Fee Schedule											472.5							Fee Schedule																				530							Case Rate																				
US NEONATAL HEAD	402	RC	76506	CPT				Both			525	236.25	40.08	530	325							Per Diem		76.17							Fee Schedule											40.08							Fee Schedule											472.5							Fee Schedule																				530							Case Rate																				
US OPTHALMIC	402	RC	76511	CPT				Both			525	236.25	29.09	530	325							Per Diem		29.09							Fee Schedule											35.44							Fee Schedule											472.5							Fee Schedule																				530							Case Rate																				
US PELVIS	402	RC	76856	CPT				Both			525	236.25	43.3	530	325							Per Diem		68.38							Fee Schedule											43.3							Fee Schedule											472.5							Fee Schedule																				530							Case Rate																				
US PELVIS LIMITED	402	RC	76857	CPT				Both			525	236.25	21.62	530	325							Per Diem		21.62							Fee Schedule											29.66							Fee Schedule											472.5							Fee Schedule																				530							Case Rate																				
US PROSTATE	402	RC	76872	CPT				Both			525	236.25	43.3	530	325							Per Diem		86.56							Fee Schedule											43.3							Fee Schedule											472.5							Fee Schedule																				530							Case Rate																				
US PROSTATE	402	RC	76872	CPT				Both			525	236.25	43.3	530	325							Per Diem		86.56							Fee Schedule											43.3							Fee Schedule											472.5							Fee Schedule																				530							Case Rate																				
US RENAL	402	RC	76770	CPT				Both			525	236.25	55.69	530	325							Per Diem		69.03							Fee Schedule											55.69							Fee Schedule											472.5							Fee Schedule																				530							Case Rate																				
US SCROTUM	402	RC	76870	CPT				Both			525	236.25	43.3	530	325							Per Diem		66.76							Fee Schedule											43.3							Fee Schedule											472.5							Fee Schedule																				530							Case Rate																				
US SPINAL CANAL	402	RC	76800	CPT				Both			525	236.25	40.08	530	325							Per Diem		76.5							Fee Schedule		94.45							Fee Schedule		40.08							Fee Schedule											472.5							Fee Schedule																				530							Case Rate																				
US SURGICAL BABCOCK 10MM #174001	272	RC						Both			254.1	114.35	114.35	228.69	165.17							Fee Schedule		188.03							Fee Schedule																													228.69							Fee Schedule																																															
US SURGICAL ENDO GIA UNIVERSAL #030449	272	RC						Both			369.6	166.32	166.32	332.64	240.24							Fee Schedule		273.5							Fee Schedule																													332.64							Fee Schedule																																															
US SURGICAL ENDO GIA XL #EGIAUNIVXL	272	RC						Both			1034.25	465.41	85.28	930.83	672.26							Fee Schedule		765.35							Fee Schedule																				91.7							Fee Schedule		930.83							Fee Schedule		105.46							Fee Schedule		85.28							Fee Schedule											105.46							Fee Schedule		85.28							Fee Schedule		
US SURGICAL ENDO SHEAR 5MM #176643	272	RC						Both			223.65	100.64	100.64	201.29	145.37							Fee Schedule		165.5							Fee Schedule																													201.29							Fee Schedule																																															
US SURGICAL LIGASURE 5 #L51500	272	RC						Both			1685.25	758.36	758.36	1516.73	1095.41							Fee Schedule		1247.09							Fee Schedule																													1516.73							Fee Schedule																																															
US SURGICAL MULTIFIRE GIA #030678L	272	RC						Both			178.5	80.33	80.33	160.65	116.03							Fee Schedule		132.09							Fee Schedule																													160.65							Fee Schedule																																															
US SURGICAL MULTIFIRE GIA#031739L	272	RC						Both			263.55	118.6	118.6	237.2	171.31							Fee Schedule		195.03							Fee Schedule																													237.2							Fee Schedule																																															
US SURGICAL MULTI-STAPLER 35 #059037	272	RC						Both			85.05	38.27	38.27	76.55	55.28							Fee Schedule		62.94							Fee Schedule																													76.55							Fee Schedule																																															
US SURGICAL PISTOL GRIP 10MM#176657	272	RC						Both			298.2	134.19	134.19	268.38	193.83							Fee Schedule		220.67							Fee Schedule																													268.38							Fee Schedule																																															
US SURGICAL PRETIE #SGL3	272	RC						Both			40.95	18.43	18.43	36.86	26.62							Fee Schedule		30.3							Fee Schedule																													36.86							Fee Schedule																																															
US SURGICAL ROTICULATOR 2.0 #030453	272	RC						Both			579.6	260.82	260.82	521.64	376.74							Fee Schedule		428.9							Fee Schedule																													521.64							Fee Schedule																																															
US SURGICAL ROTICULATOR 2.5  #030457	272	RC						Both			618.45	278.3	278.3	556.61	401.99							Fee Schedule		457.65							Fee Schedule																													556.61							Fee Schedule																																															
US SURGICAL ROTICULATOR 3.5 #030458	272	RC						Both			618.45	278.3	278.3	556.61	401.99							Fee Schedule		457.65							Fee Schedule																													556.61							Fee Schedule																																															
US SURGICAL SING.LOAD UNIT 3TA4535L	272	RC						Both			185.85	83.63	83.63	167.27	120.8							Fee Schedule		137.53							Fee Schedule																													167.27							Fee Schedule																																															
US SURGICAL SINGLE LOADING UNIT  TA9048L	272	RC						Both			747	336.15	336.15	672.3	485.55							Fee Schedule		552.78							Fee Schedule																													672.3							Fee Schedule																																															
US SURGICAL SINGLE RELOAD#TA9048S/015084	272	RC						Both			1225	551.25	551.25	1102.5	796.25							Fee Schedule		906.5							Fee Schedule																													1102.5							Fee Schedule																																															
US SURGICAL SINGLE UNIT #TA6035L	272	RC						Both			157.5	70.88	70.88	141.75	102.38							Fee Schedule		116.55							Fee Schedule																													141.75							Fee Schedule																																															
US SURGICAL STRAIGHT #030418	272	RC						Both			393.75	177.19	177.19	354.38	255.94							Fee Schedule		291.38							Fee Schedule																													354.38							Fee Schedule																																															
US SURGICAL SURGICLIP #134044	272	RC						Both			178.5	80.33	80.33	160.65	116.03							Fee Schedule		132.09							Fee Schedule																													160.65							Fee Schedule																																															
US SURGICAL SURGINEEDLE 120MM #172015	272	RC						Both			68.25	30.71	30.71	61.43	44.36							Fee Schedule		50.51							Fee Schedule																													61.43							Fee Schedule																																															
US SURGICAL VERSA 5-12MM TRC#179096P	272	RC						Both			182.7	82.22	82.22	164.43	118.76							Fee Schedule		135.2							Fee Schedule																													164.43							Fee Schedule																																															
US SURGICAL VERSA 5-8MM 179074P *DISC.*	272	RC						Both			442.05	198.92	198.92	397.85	287.33							Fee Schedule		327.12							Fee Schedule																													397.85							Fee Schedule																																															
US SURGICAL VERSA 5MM TROCAR #179094	272	RC						Both			150.15	67.57	67.57	135.14	97.6							Fee Schedule		111.11							Fee Schedule																													135.14							Fee Schedule																																															
US SURGICAL VERSA STEP #VS150000	272	RC						Both			93.45	42.05	42.05	84.11	60.74							Fee Schedule		69.15							Fee Schedule																													84.11							Fee Schedule																																															
US SURGICAL VERSA STEP 12MM #VS101512P	272	RC						Both			264.6	119.07	119.07	238.14	171.99							Fee Schedule		195.8							Fee Schedule																													238.14							Fee Schedule																																															
US SURGICAL VERSA STEP 5MM TROC.#VS10150	272	RC						Both			219.45	98.75	98.75	197.51	142.64							Fee Schedule		162.39							Fee Schedule																													197.51							Fee Schedule																																															
US SURGICAL VERSAPORT #177092	272	RC						Both			101.85	45.83	45.83	91.67	66.2							Fee Schedule		75.37							Fee Schedule																													91.67							Fee Schedule																																															
US SURGICAL VERSAPORT PLUS #177091P	272	RC						Both			118.65	53.39	53.39	106.79	77.12							Fee Schedule		87.8							Fee Schedule																													106.79							Fee Schedule																																															
US SURGICAL VERSASLEEVE #VS101500	272	RC						Both			175.35	78.91	78.91	157.82	113.98							Fee Schedule		129.76							Fee Schedule																													157.82							Fee Schedule																																															
US SURGICAL VRSPT+ 5-12MM #179097P	272	RC						Both			393.75	177.19	177.19	354.38	255.94							Fee Schedule		291.38							Fee Schedule																													354.38							Fee Schedule																																															
US THYROID	402	RC	76536	CPT				Both			525	236.25	40.08	530	325							Per Diem		79.42							Fee Schedule											40.08							Fee Schedule											472.5							Fee Schedule																				530							Case Rate																				
US TRANSVAGINAL	402	RC	76830	CPT				Both			525	236.25	43.3	530	325							Per Diem		79.42							Fee Schedule											43.3							Fee Schedule											472.5							Fee Schedule																				530							Case Rate																				
USTEKINUMAB QN WITH ANTIBODIES 39986	301	RC						Both			519	233.55	233.55	467.1	337.35							Fee Schedule		384.06							Fee Schedule																													467.1							Fee Schedule																																															
UTA CAPSULE	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
SIGNS AND SYMPTOMS WITHOUT MCC					948	DRG		Inpatient			20059.6	9026.82	9026.82	9026.82							0		No services performed during 15 month lookback period. 				7886.83	7886.83	7886.83	1 through 10						6583.34	6583.34	6583.34	1 through 10									0		No services provided during 15 month lookback period				4960.59	4960.59	4960.59	1 through 10									0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period	
UTERINE MANIPULATOR	272	RC						Both			128.1	57.65	57.65	115.29	83.27							Fee Schedule		94.79							Fee Schedule																													115.29							Fee Schedule																																															
UTERINE MANIPULATOR UM201	272	RC						Both			128.1	57.65	57.65	115.29	83.27							Fee Schedule		94.79							Fee Schedule																													115.29							Fee Schedule																																															
UTILITY DRAPE STERILE 15 X26  #DYNJP2405	272	RC						Both			0.9	0.41	0.41	0.81	0.59							Fee Schedule		0.67							Fee Schedule																													0.81							Fee Schedule																																															
UTILITY MARKER #DYNJSM07	270	RC						Both			2	0.9	0.9	1.8	1.3							Fee Schedule		1.48							Fee Schedule																													1.8							Fee Schedule																																															
VA ANKLE/BRACHIAL INDICES	921	RC	93922	CPT				Both			791.7	356.27	35.49	800	507							Per Diem		585.86							Fee Schedule											35.49							Fee Schedule											712.53							Fee Schedule																				800							Per Diem																				
VA ART ILC IVC DP BI COMP	921	RC	93925	CPT				Both			791.7	356.27	108.35	800	507							Per Diem		585.86							Fee Schedule											108.35							Fee Schedule											712.53							Fee Schedule																				800							Per Diem																				
VA CAROTID ULTRASOUND	921	RC	93880	CPT				Both			791.7	356.27	108.35	800	507							Per Diem		585.86							Fee Schedule											108.35							Fee Schedule											712.53							Fee Schedule																				800							Per Diem																				
VA LW EX ART DP UN LIM	921	RC	93926	CPT				Both			791.7	356.27	94.21	800	507							Per Diem		585.86							Fee Schedule		94.21							Fee Schedule		108.35							Fee Schedule											712.53							Fee Schedule																				800							Per Diem																				
VA LW EX ART DUP CO BI	921	RC	93925	CPT				Both			791.7	356.27	108.35	800	507							Per Diem		585.86							Fee Schedule											108.35							Fee Schedule											712.53							Fee Schedule																				800							Per Diem																				
VA PENILE DUPLEX VASCULAR	921	RC	93980	CPT				Both			791.7	356.27	108.35	800	507							Per Diem		585.86							Fee Schedule											108.35							Fee Schedule											712.53							Fee Schedule																				800							Per Diem																				
VA RENAL ART/CELIAC DUP	921	RC	93975	CPT				Both			791.7	356.27	85.07	800	507							Per Diem		585.86							Fee Schedule											108.35							Fee Schedule		91.47							Fee Schedule		712.53							Fee Schedule		105.19							Fee Schedule		85.07							Fee Schedule		800							Per Diem		105.19							Fee Schedule		85.07							Fee Schedule		
VA UP EXT ART UNI	921	RC	93931	CPT				Both			791.7	356.27	108.35	800	507							Per Diem		585.86							Fee Schedule											108.35							Fee Schedule											712.53							Fee Schedule																				800							Per Diem																				
VA UPPER EXT ART BILATERAL	921	RC	93930	CPT				Both			791.7	356.27	108.35	800	507							Per Diem		585.86							Fee Schedule											108.35							Fee Schedule											712.53							Fee Schedule																				800							Per Diem																				
VA VENOUS DUPLEX BILATERAL	921	RC	93970	CPT				Both			791.7	356.27	108.35	800	507							Per Diem		585.86							Fee Schedule											108.35							Fee Schedule											712.53							Fee Schedule																				800							Per Diem																				
VA VENOUS UNILATERAL	921	RC	93971	CPT				Both			791.7	356.27	108.35	800	507							Per Diem		585.86							Fee Schedule											108.35							Fee Schedule											712.53							Fee Schedule																				800							Per Diem																				
VACCUM CUP (OB SCIENTIFIC)	272	RC						Both			75.6	34.02	34.02	68.04	49.14							Fee Schedule		55.94							Fee Schedule																													68.04							Fee Schedule																																															
VACUUM CANISTER 800CC REPLACE MCANISTER1	272	RC	A7000	CPT				Both			12	5.4	5.4	10.82	6.56							Fee Schedule		8.88							Fee Schedule		10.82							Fee Schedule																				10.8							Fee Schedule																																															
VACUUM CUP #600TT  ( UTAH MEDICAL )	272	RC						Both			71.4	32.13	32.13	64.26	46.41							Fee Schedule		52.84							Fee Schedule																													64.26							Fee Schedule																																															
VAG IRRIGATION BAG	271	RC						Both			7.35	3.31	3.31	6.62	4.78							Fee Schedule		5.44							Fee Schedule																													6.62							Fee Schedule																																															
VAGINAL BETA STREP GROUP B CULTURE	300	RC	87081	CPT				Both			75.6	34.02	5.89	68.04	5.89							Fee Schedule		7.36							Fee Schedule		6.83							Fee Schedule		6.63							Fee Schedule		10.5							Fee Schedule		68.04							Fee Schedule		12.08							Fee Schedule		9.77							Fee Schedule		6.63							Fee Schedule		12.08							Fee Schedule		9.77							Fee Schedule		
OTHER FACTORS INFLUENCING HEALTH STATUS					951	DRG		Inpatient			11275.99	5074.19	5074.19	5074.19							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback				5888.96	5888.96	5888.96	1 through 10									0		No services provided during 15 month lookback period	
"LIMB REATTACHMENT, HIP AND FEMUR PROCEDURES FOR MULTIPLE SIG"					956	DRG		Inpatient			32831.65	14774.24	14774.24	14774.24							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period	
EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS W					981	DRG		Inpatient			170078.24	76535.21	76535.21	76535.21							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period							0		No services provided during 15 month lookback period				1083.59	1083.59	1083.59	1 through 10									0		No services provided during 15 month lookback period							0	Fee Schedule	No services provided during 15 month lookback period							0	Fee Schedule	No services provided during 15 month lookback period							0		No services provided during 15 month lookback							0		No services provided during 15 month lookback period							0	Fee Schedule	No services provided during 15 month lookback period	
EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS W					983	DRG		Inpatient			40727.4	18327.33	18327.33	18327.33							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period	
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOS					987	DRG		Inpatient			227004.77	102152.15	102152.15	102152.15							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period	
VAGINAL SPEC. LARGE CORDLESS 59004	271	RC						Both			7	3.15	3.15	6.3	4.55							Fee Schedule		5.18							Fee Schedule																													6.3							Fee Schedule																																															
VAGINAL SPEC. SMALL CORDLESS 59000	271	RC						Both			5	2.25	2.25	4.5	3.25							Fee Schedule		3.7							Fee Schedule																													4.5							Fee Schedule																																															
VAGINAL SPECULUMS SMALL # 58000S (DISC.)	271	RC						Both			6.3	2.84	2.84	5.67	4.1							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
VAGINAL TABLET APPLICATOR  #VAGAP100	272	RC						Both			21	9.45	9.45	18.9	13.65							Fee Schedule		15.54							Fee Schedule																													18.9							Fee Schedule																																															
VALPROATE SODIUM 500 MG/NS 100ML IVPB	250	RC	A9270	CPT				Both			16.8	7.56	0.01	15.12	0.01							Fee Schedule		12.43							Fee Schedule																													15.12							Fee Schedule																																															
VALPROATE SODIUM 500MG VIAL	636	RC	J1165	CPT				Both			12.6	5.67	0.56	11.34		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	9.32							Fee Schedule		0.56							Fee Schedule		1.29							Fee Schedule											11.34							Fee Schedule																																															
VALPROIC ACID 250 MG/5ML SYRUP (DEPAKENE	250	RC	A9270	CPT				Both			8.4	3.78	0.01	7.56	0.01							Fee Schedule		6.22							Fee Schedule																													7.56							Fee Schedule																																															
VALPROIC ACID 500MG/10ML SOL (DEPAKENE)	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
VALSARTAN (DIOVAN)  40MG TABLET	250	RC	A9270	CPT				Both			12.6	5.67	0.01	11.34	0.01							Fee Schedule		9.32							Fee Schedule																				0.55							Fee Schedule		11.34							Fee Schedule		0.63							Fee Schedule		0.51							Fee Schedule											0.63							Fee Schedule		0.51							Fee Schedule		
VALSARTAN (DIOVAN)  80MG TABLET	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
VALSARTAN (DIOVAN) 160MG TABLET	250	RC	A9270	CPT				Both			16.8	7.56	0.01	15.12	0.01							Fee Schedule		12.43							Fee Schedule																													15.12							Fee Schedule																																															
VALTREX 1000 MG TABLET UD	250	RC	A9270	CPT				Both			16.25	7.31	0.01	14.63	0.01							Fee Schedule		12.03							Fee Schedule																													14.63							Fee Schedule																																															
VALTREX 500 MG (VALACYCLOVIR) TABLET	250	RC	A9270	CPT				Both			24.15	10.87	0.01	21.74	0.01							Fee Schedule		17.87							Fee Schedule																													21.74							Fee Schedule																																															
VALVED TEE ADAPTER MEDLINE HCSA1008	271	RC						Both			4	1.8	1.8	3.6	2.6							Fee Schedule		2.96							Fee Schedule																													3.6							Fee Schedule																																															
VANADIUM  5386   4ML SERUM	300	RC	83018	CPT				Both			142.8	64.26	19.53	128.52	19.53							Fee Schedule		24.41							Fee Schedule		22.62							Fee Schedule		21.96							Fee Schedule											128.52							Fee Schedule																				21.96							Fee Schedule																				
VANCENASE AQ DS	636	RC	J3535	CPT				Both			139.2	62.64	62.64	125.28		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	103.01							Fee Schedule																													125.28							Fee Schedule																																															
VANCERIL 84MCG (DS) MDI	636	RC	J3535	CPT				Both			143.23	64.45	64.45	128.91		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	105.99							Fee Schedule																													128.91							Fee Schedule																																															
VANCERIL INH:16.8GM	636	RC	J3535	CPT				Both			83.51	37.58	20.42	75.16		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	61.8							Fee Schedule																				21.96							Fee Schedule		75.16							Fee Schedule		25.25							Fee Schedule		20.42							Fee Schedule											25.25							Fee Schedule		20.42							Fee Schedule		
VANCOCIN 125 MG (VANCOMYCIN) CAPSULE	250	RC	A9270	CPT				Both			98.7	44.42	0.01	88.83	0.01							Fee Schedule		73.04							Fee Schedule																													88.83							Fee Schedule																																															
VANCOMYCIN  1 GM PREMIX	636	RC	J3375	CPT				Both			113.4	51.03	0.15	102.06		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	0.16							Fee Schedule		0.15							Fee Schedule																				102.06							Fee Schedule																																															
VANCOMYCIN  1 GM/NS 200 ML PREMIX	636	RC	J3372	CPT				Both			113.4	51.03	51.03	102.06		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	83.92							Fee Schedule																													102.06							Fee Schedule																																															
VANCOMYCIN  1250MG/NS 250 ML IVPB	636	RC	J3373	CPT				Both			129.66	58.35	0.03	116.69		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	95.95							Fee Schedule		0.03							Fee Schedule																				116.69							Fee Schedule																																															
VANCOMYCIN  1500MG/NS 250 ML IVPB	636	RC	J3373	CPT				Both			129.66	58.35	0.03	116.69		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	95.95							Fee Schedule		0.03							Fee Schedule											0.14							Fee Schedule		116.69							Fee Schedule		0.16							Fee Schedule		0.13							Fee Schedule											0.16							Fee Schedule		0.13							Fee Schedule		
VANCOMYCIN  1750MG/NS 500 ML IVPB	636	RC	J3373	CPT				Both			127.35	57.31	0.03	114.62		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	94.24							Fee Schedule		0.03							Fee Schedule																				114.62							Fee Schedule																																															
VANCOMYCIN  1GM/NS 250 ML IVPB	636	RC	J3373	CPT				Both			71.91	32.36	0.03	64.72		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	53.21							Fee Schedule		0.03							Fee Schedule											0.03							Fee Schedule		64.72							Fee Schedule		0.04							Fee Schedule		0.03							Fee Schedule											0.04							Fee Schedule		0.03							Fee Schedule		
VANCOMYCIN  2GM/NS 500 ML IVPB	636	RC	J3373	CPT				Both			127.35	57.31	0.03	114.62		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	94.24							Fee Schedule		0.03							Fee Schedule											0.03							Fee Schedule		114.62							Fee Schedule		0.04							Fee Schedule		0.03							Fee Schedule											0.04							Fee Schedule		0.03							Fee Schedule		
VANCOMYCIN  350MG/NS 100 ML IVPB	636	RC	J3373	CPT				Both			52.5	23.63	0.03	47.25		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	38.85							Fee Schedule		0.03							Fee Schedule											0.03							Fee Schedule		47.25							Fee Schedule		0.04							Fee Schedule		0.03							Fee Schedule											0.04							Fee Schedule		0.03							Fee Schedule		
VANCOMYCIN  500 MG PREMIX	636	RC	J3375	CPT				Both			56.7	25.52	0.03	51.03		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	0.16							Fee Schedule		0.15							Fee Schedule											0.03							Fee Schedule		51.03							Fee Schedule		0.04							Fee Schedule		0.03							Fee Schedule											0.04							Fee Schedule		0.03							Fee Schedule		
VANCOMYCIN  500MG/NS 100 ML IVPB	636	RC	J3373	CPT				Both			38.43	17.29	0.03	34.59		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	28.44							Fee Schedule		0.03							Fee Schedule											0.03							Fee Schedule		34.59							Fee Schedule		0.04							Fee Schedule		0.03							Fee Schedule											0.04							Fee Schedule		0.03							Fee Schedule		
VANCOMYCIN  600MG/NS 250 ML IVPB	636	RC	J3373	CPT				Both			89.25	40.16	0.03	80.33		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	66.05							Fee Schedule		0.03							Fee Schedule											0.03							Fee Schedule		80.33							Fee Schedule		0.04							Fee Schedule		0.03							Fee Schedule											0.04							Fee Schedule		0.03							Fee Schedule		
VANCOMYCIN  650MG/NS 250 ML IVPB	636	RC	J3374	CPT				Both			89.25	40.16	0.1	80.33		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	0.1							Fee Schedule		0.1							Fee Schedule											0.14							Fee Schedule		80.33							Fee Schedule		0.16							Fee Schedule		0.13							Fee Schedule											0.16							Fee Schedule		0.13							Fee Schedule		
VANCOMYCIN  750MG/NS 250 ML IVPB	636	RC	J3374	CPT				Both			49.05	22.07	0.03	44.15		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	0.1							Fee Schedule		0.1							Fee Schedule											0.03							Fee Schedule		44.15							Fee Schedule		0.04							Fee Schedule		0.03							Fee Schedule											0.04							Fee Schedule		0.03							Fee Schedule		
VANCOMYCIN  PEAK	301	RC	80202	CPT				Both			106.05	47.72	0.03	95.45	12.04							Fee Schedule		15.05							Fee Schedule		13.95							Fee Schedule		13.54							Fee Schedule		0.03							Fee Schedule		95.45							Fee Schedule		0.04							Fee Schedule		0.03							Fee Schedule		13.54							Fee Schedule		0.04							Fee Schedule		0.03							Fee Schedule		
VANCOMYCIN  RANDOM	301	RC	80202	CPT				Both			106.05	47.72	0.09	95.45	12.04							Fee Schedule		15.05							Fee Schedule		13.95							Fee Schedule		13.54							Fee Schedule		0.1							Fee Schedule		95.45							Fee Schedule		0.11							Fee Schedule		0.09							Fee Schedule		13.54							Fee Schedule		0.11							Fee Schedule		0.09							Fee Schedule		
VANCOMYCIN : 500 MG VIAL	636	RC	J3370	CPT				Both			34.44	15.5	0.09	31		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	25.49							Fee Schedule																				0.1							Fee Schedule		31							Fee Schedule		0.11							Fee Schedule		0.09							Fee Schedule											0.11							Fee Schedule		0.09							Fee Schedule		
VANCOMYCIN :5GM (VANCOCIN) VIAL-BULK	636	RC	J3370	CPT				Both			92.4	41.58	12.59	83.16		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	68.38							Fee Schedule																				13.54							Fee Schedule		83.16							Fee Schedule		15.57							Fee Schedule		12.59							Fee Schedule											15.57							Fee Schedule		12.59							Fee Schedule		
VANCOMYCIN 1.25GM VIAL	636	RC	J3374	CPT				Both			72.36	32.56	0.1	65.12		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	0.1							Fee Schedule		0.1							Fee Schedule											13.54							Fee Schedule		65.12							Fee Schedule		15.57							Fee Schedule		12.59							Fee Schedule											15.57							Fee Schedule		12.59							Fee Schedule		
VANCOMYCIN 1.5GM VIAL	636	RC	J3373	CPT				Both			86.82	39.07	0.03	78.14		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	64.25							Fee Schedule		0.03							Fee Schedule																				78.14							Fee Schedule																																															
VANCOMYCIN 1.75GM VIAL	636	RC	J3374	CPT				Both			134.82	60.67	0.1	121.34		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	0.1							Fee Schedule		0.1							Fee Schedule																				121.34							Fee Schedule																																															
VANCOMYCIN 1200 MG/NS 250 ML IVPB	636	RC	J3374	CPT				Both			89.25	40.16	0.09	80.33		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	0.1							Fee Schedule		0.1							Fee Schedule											0.1							Fee Schedule		80.33							Fee Schedule		0.11							Fee Schedule		0.09							Fee Schedule											0.11							Fee Schedule		0.09							Fee Schedule		
VANCOMYCIN 1250 MG PREMIX	636	RC	J3375	CPT				Both			68.4	30.78	0.03	61.56		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	0.16							Fee Schedule		0.15							Fee Schedule											0.03							Fee Schedule		61.56							Fee Schedule		0.04							Fee Schedule		0.03							Fee Schedule											0.04							Fee Schedule		0.03							Fee Schedule		
VANCOMYCIN 1500 MG PREMIX	636	RC	J3375	CPT				Both			170.1	76.55	0.09	153.09		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	0.16							Fee Schedule		0.15							Fee Schedule											0.1							Fee Schedule		153.09							Fee Schedule		0.11							Fee Schedule		0.09							Fee Schedule											0.11							Fee Schedule		0.09							Fee Schedule		
VANCOMYCIN 1750 MG PREMIX	636	RC	J3375	CPT				Both			198.45	89.3	0.09	178.61		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	0.16							Fee Schedule		0.15							Fee Schedule											0.1							Fee Schedule		178.61							Fee Schedule		0.11							Fee Schedule		0.09							Fee Schedule											0.11							Fee Schedule		0.09							Fee Schedule		
VANCOMYCIN 1GM (VANCOCIN) VIAL	636	RC	J3373	CPT				Both			57.75	25.99	0.03	51.98		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	42.74							Fee Schedule		0.03							Fee Schedule											0.14							Fee Schedule		51.98							Fee Schedule		0.16							Fee Schedule		0.13							Fee Schedule											0.16							Fee Schedule		0.13							Fee Schedule		
VANCOMYCIN 2 GM PREMIX	636	RC	J3375	CPT				Both			226.8	102.06	0.13	204.12		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	0.16							Fee Schedule		0.15							Fee Schedule											0.14							Fee Schedule		204.12							Fee Schedule		0.16							Fee Schedule		0.13							Fee Schedule											0.16							Fee Schedule		0.13							Fee Schedule		
VANCOMYCIN 2250MG /NS 500 ML IVPB	636	RC	J3373	CPT				Both			141.75	63.79	0.03	127.58		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	104.9							Fee Schedule		0.03							Fee Schedule											0.14							Fee Schedule		127.58							Fee Schedule		0.16							Fee Schedule		0.13							Fee Schedule											0.16							Fee Schedule		0.13							Fee Schedule		
VANCOMYCIN 2500MG /NS 500 ML IVPB	636	RC	J3373	CPT				Both			141.75	63.79	0.03	127.58		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	104.9							Fee Schedule		0.03							Fee Schedule											0.03							Fee Schedule		127.58							Fee Schedule		0.04							Fee Schedule		0.03							Fee Schedule											0.04							Fee Schedule		0.03							Fee Schedule		
VANCOMYCIN 2GM VIAL	636	RC	J3374	CPT				Both			154.08	69.34	0.1	138.67		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	0.1							Fee Schedule		0.1							Fee Schedule											0.14							Fee Schedule		138.67							Fee Schedule		0.16							Fee Schedule		0.13							Fee Schedule											0.16							Fee Schedule		0.13							Fee Schedule		
VANCOMYCIN 500 MG (VANCOCIN) VIAL	636	RC	J3373	CPT				Both			29.37	13.22	0.03	26.43		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	21.73							Fee Schedule		0.03							Fee Schedule											0.03							Fee Schedule		26.43							Fee Schedule		0.04							Fee Schedule		0.03							Fee Schedule											0.04							Fee Schedule		0.03							Fee Schedule		
VANCOMYCIN 500MG VIAL (SOLUSET)	250	RC	J3373	CPT				Both			29.37	13.22	0.03	26.43	19.09							Fee Schedule		21.73							Fee Schedule		0.03							Fee Schedule											0.03							Fee Schedule		26.43							Fee Schedule		0.04							Fee Schedule		0.03							Fee Schedule											0.04							Fee Schedule		0.03							Fee Schedule		
VANCOMYCIN 750 MG PREMIX	636	RC	J3375	CPT				Both			85.05	38.27	0.09	76.55		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	0.16							Fee Schedule		0.15							Fee Schedule											0.1							Fee Schedule		76.55							Fee Schedule		0.11							Fee Schedule		0.09							Fee Schedule											0.11							Fee Schedule		0.09							Fee Schedule		
VANCOMYCIN 750MG VIAL	636	RC	J3373	CPT				Both			34.89	15.7	0.03	31.4		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	25.82							Fee Schedule		0.03							Fee Schedule											0.03							Fee Schedule		31.4							Fee Schedule		0.04							Fee Schedule		0.03							Fee Schedule											0.04							Fee Schedule		0.03							Fee Schedule		
VANCOMYCIN TROUGH	301	RC	80202	CPT				Both			106.05	47.72	0.03	95.45	12.04							Fee Schedule		15.05							Fee Schedule		13.95							Fee Schedule		13.54							Fee Schedule		0.03							Fee Schedule		95.45							Fee Schedule		0.04							Fee Schedule		0.03							Fee Schedule		13.54							Fee Schedule		0.04							Fee Schedule		0.03							Fee Schedule		
VANILLYLMANDELIC ACID  VMA  934 URINE	301	RC	84585	CPT				Both			84	37.8	0.13	75.6	13.77							Fee Schedule		17.22							Fee Schedule		15.97							Fee Schedule		15.5							Fee Schedule		0.14							Fee Schedule		75.6							Fee Schedule		0.16							Fee Schedule		0.13							Fee Schedule		15.5							Fee Schedule		0.16							Fee Schedule		0.13							Fee Schedule		
VANTIN 100 MG/5ML ORAL SUSP-50ML	250	RC	A9270	CPT				Both			139.65	62.84	0.01	125.69	0.01							Fee Schedule		103.34							Fee Schedule																				0.03							Fee Schedule		125.69							Fee Schedule		0.04							Fee Schedule		0.03							Fee Schedule											0.04							Fee Schedule		0.03							Fee Schedule		
VAP TM CHOLESTEROL 10270 1ML SERUM	301	RC	84478	CPT				Both			119.7	53.87	5.1	107.73	5.1							Fee Schedule		6.38							Fee Schedule		5.91							Fee Schedule		5.74							Fee Schedule		13.54							Fee Schedule		107.73							Fee Schedule		15.57							Fee Schedule		12.59							Fee Schedule		5.74							Fee Schedule		15.57							Fee Schedule		12.59							Fee Schedule		
VAPONEFRIN PER ML (RT)	250	RC						Both			1.58	0.71	0.71	17.83	1.03							Fee Schedule		1.17							Fee Schedule																				15.5							Fee Schedule		1.42							Fee Schedule		17.83							Fee Schedule		14.42							Fee Schedule											17.83							Fee Schedule		14.42							Fee Schedule		
VARENICLINE 0.5 MG TABLET	250	RC	A9270	CPT				Both			8.4	3.78	0.01	7.56	0.01							Fee Schedule		6.22							Fee Schedule																													7.56							Fee Schedule																																															
VARICELLA VACCINE (CHICKEN POX)	636	RC	90716	CPT				Both			197.4	88.83	5.34	177.66		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	146.08							Fee Schedule											77.12							Fee Schedule		5.74							Fee Schedule		177.66							Fee Schedule		6.6							Fee Schedule		5.34							Fee Schedule											6.6							Fee Schedule		5.34							Fee Schedule		
VARICELLA ZOSTER  SWAB 3650	302	RC	86787	CPT				Both			73.5	33.08	11.45	66.15	11.45							Fee Schedule		14.31							Fee Schedule		13.27							Fee Schedule		12.88							Fee Schedule											66.15							Fee Schedule																				12.88							Fee Schedule																				
VARICELLA ZOSTER IGG SERUM 4439)	302	RC	86787	CPT				Both			68.25	30.71	11.45	61.43	11.45							Fee Schedule		14.31							Fee Schedule		13.27							Fee Schedule		12.88							Fee Schedule											61.43							Fee Schedule																				12.88							Fee Schedule																				
VARICELLA ZOSTER IGM SERUM 8683	302	RC	86787	CPT				Both			97.65	43.94	11.45	87.89	11.45							Fee Schedule		14.31							Fee Schedule		13.27							Fee Schedule		12.88							Fee Schedule											87.89							Fee Schedule																				12.88							Fee Schedule																				
VARICELLA ZOSTER VIRUS 2691 RM CULTURE	302	RC	87254	CPT				Both			162	72.9	11.98	145.8	17.39							Fee Schedule		21.73							Fee Schedule		20.15							Fee Schedule		19.56							Fee Schedule		12.88							Fee Schedule		145.8							Fee Schedule		14.81							Fee Schedule		11.98							Fee Schedule		19.56							Fee Schedule		14.81							Fee Schedule		11.98							Fee Schedule		
"VARICELLA-ZOSTER VIRUS DNA, QUAL 34052"	302	RC	87798	CPT				Both			342	153.9	11.98	307.8	31.2							Fee Schedule		38.99							Fee Schedule		36.14							Fee Schedule		35.09							Fee Schedule		12.88							Fee Schedule		307.8							Fee Schedule		14.81							Fee Schedule		11.98							Fee Schedule		35.09							Fee Schedule		14.81							Fee Schedule		11.98							Fee Schedule		
VASCOR 200MG TABLET	250	RC	A9270	CPT				Both			6.62	2.98	0.01	14.81	0.01							Fee Schedule		4.9							Fee Schedule																				12.88							Fee Schedule		5.96							Fee Schedule		14.81							Fee Schedule		11.98							Fee Schedule											14.81							Fee Schedule		11.98							Fee Schedule		
VASCULAR BARE TIP NEEDLE 78050 *DISC.*	272	RC						Both			488	219.6	18.19	439.2	317.2							Fee Schedule		361.12							Fee Schedule																				19.56							Fee Schedule		439.2							Fee Schedule		22.49							Fee Schedule		18.19							Fee Schedule											22.49							Fee Schedule		18.19							Fee Schedule		
"VASCULAR ENDOTHELIAL GF, (VEGF) 14512"	301	RC	83520	CPT				Both			410.43	184.69	12.43	369.39	12.43							Fee Schedule		17.27							Fee Schedule		17.79							Fee Schedule		17.27							Fee Schedule		35.09							Fee Schedule		369.39							Fee Schedule		40.35							Fee Schedule		32.63							Fee Schedule		17.27							Fee Schedule		40.35							Fee Schedule		32.63							Fee Schedule		
VASCULAR GRAFT BIFURC.STRETCH #SBT2001	278	RC	C1876	CPT				Both			2629.2	1183.14	1183.14	2366.28		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1945.61							Fee Schedule																													2366.28							Fee Schedule																																															
VASCULAR GRAFT PROPATEN H470045A ( GORE	278	RC	C1768	CPT				Both			3994.2	1797.39	1797.39	3594.78		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	2955.71							Fee Schedule																													3594.78							Fee Schedule																																															
VASCULAR GRAFT PROPATEN HT066080A ( GORE	278	RC	C1768	CPT				Both			8656.2	3895.29	16.06	7790.58		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	6405.59							Fee Schedule																				17.27							Fee Schedule		7790.58							Fee Schedule		19.86							Fee Schedule		16.06							Fee Schedule											19.86							Fee Schedule		16.06							Fee Schedule		
VASCULAR GRAFT PROPATEN HT067090A ( GORE	278	RC	C1768	CPT				Both			9242.1	4158.95	4158.95	8317.89		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	6839.15							Fee Schedule																													8317.89							Fee Schedule																																															
VASCULAR GRAFT PROPATEN HT076080A ( GORE	278	RC	C1768	CPT				Both			8649.9	3892.46	3892.46	7784.91		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	6400.93							Fee Schedule																													7784.91							Fee Schedule																																															
VASCULAR GRAFT PROPATEN HT087080A ( GORE	278	RC	C1768	CPT				Both			9103.5	4096.58	4096.58	8193.15		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	6736.59							Fee Schedule																													8193.15							Fee Schedule																																															
VASCULAR GRAFT PROPATEN HT087090A ( GORE	278	RC	C1768	CPT				Both			8988	4044.6	4044.6	8089.2		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	6651.12							Fee Schedule																													8089.2							Fee Schedule																																															
VASCULAR GRAFT PROPATEN HT087090A ( GORE	278	RC	C1768	CPT				Both			8988	4044.6	4044.6	8089.2		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	6651.12							Fee Schedule																													8089.2							Fee Schedule																																															
VASCULAR SUTURE BOOTIES # VB1110	272	RC						Both			6	2.7	2.7	5.4	3.9							Fee Schedule		4.44							Fee Schedule																													5.4							Fee Schedule																																															
VASELINE 1 OZ	250	RC	A9270	CPT				Both			1.51	0.68	0.01	1.36	0.01							Fee Schedule		1.12							Fee Schedule																													1.36							Fee Schedule																																															
VASELINE 16 OZ	250	RC	A9270	CPT				Both			19.22	8.65	0.01	17.3	0.01							Fee Schedule		14.22							Fee Schedule																													17.3							Fee Schedule																																															
VASELINE DRESSING 3  X 36	272	RC	A6223	CPT				Both			3.31	1.49	1.49	3.56	2.18							Fee Schedule		2.45							Fee Schedule		3.56							Fee Schedule		2.73							Fee Schedule											2.98							Fee Schedule																																															
VASELINE GAUSE	272	RC						Both			4.2	1.89	1.89	3.78	2.73							Fee Schedule		3.11							Fee Schedule																													3.78							Fee Schedule																																															
VASELINE GAUZE 3X3	272	RC						Both			5.25	2.36	2.36	4.73	3.41							Fee Schedule		3.89							Fee Schedule																													4.73							Fee Schedule																																															
VASELINE GAUZE 3X36	272	RC	A6223	CPT				Both			5.25	2.36	2.18	4.73	2.18							Fee Schedule		3.89							Fee Schedule		3.56							Fee Schedule		2.73							Fee Schedule		3.46							Fee Schedule		4.73							Fee Schedule		3.98							Fee Schedule		3.22							Fee Schedule											3.98							Fee Schedule		3.22							Fee Schedule		
VASELINE GAUZE 3X36	272	RC						Both			4.2	1.89	1.89	3.78	2.73							Fee Schedule		3.11							Fee Schedule																													3.78							Fee Schedule																																															
VASELINE GAUZE PACK STRIP #421600	272	RC						Both			5.25	2.36	2.36	4.73	3.41							Fee Schedule		3.89							Fee Schedule																													4.73							Fee Schedule																																															
VASELINE JELLY 30GM	250	RC	A9270	CPT				Both			1.98	0.89	0.01	3.98	0.01							Fee Schedule		1.47							Fee Schedule																				3.46							Fee Schedule		1.78							Fee Schedule		3.98							Fee Schedule		3.22							Fee Schedule											3.98							Fee Schedule		3.22							Fee Schedule		
VASHE SOLUTION 250ML #00313	270	RC	A6260	CPT				Both			43	19.35	0.52	38.7	0.52							Fee Schedule		31.82							Fee Schedule																													38.7							Fee Schedule																																															
VASHE WOUND SOLUTION 475ML	250	RC	A9270	CPT				Both			160.65	72.29	0.01	144.59	0.01							Fee Schedule		118.88							Fee Schedule																													144.59							Fee Schedule																																															
VASOACTIVE INTESTINAL POLYPEPTIDE 901629	301	RC	84586	CPT				Both			101.85	45.83	31.41	91.67	31.41							Fee Schedule		39.26							Fee Schedule		36.39							Fee Schedule		35.33							Fee Schedule											91.67							Fee Schedule																				35.33							Fee Schedule																				
VASOCIDIN OPTH SOL	250	RC	A9270	CPT				Both			41.2	18.54	0.01	37.08	0.01							Fee Schedule		30.49							Fee Schedule																													37.08							Fee Schedule																																															
VASOCON-A OPTH SOL	250	RC	A9270	CPT				Both			23.63	10.63	0.01	21.27	0.01							Fee Schedule		17.49							Fee Schedule																													21.27							Fee Schedule																																															
VASODILAN 10 MG TABLET UD	250	RC	A9270	CPT				Both			2.1	0.95	0.01	40.63	0.01							Fee Schedule		1.55							Fee Schedule																				35.33							Fee Schedule		1.89							Fee Schedule		40.63							Fee Schedule		32.86							Fee Schedule											40.63							Fee Schedule		32.86							Fee Schedule		
VASOPRESSIN 20 UNITS/ML-1 ML SDV	636	RC	J2598	CPT				Both			525	236.25	0.5	472.5		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	388.5							Fee Schedule		0.5							Fee Schedule																				472.5							Fee Schedule																																															
VASOPRESSIN 20 UNITS/ML-10ML MDV	250	RC						Both			73.5	33.08	33.08	66.15	47.78							Fee Schedule		54.39							Fee Schedule																													66.15							Fee Schedule																																															
VASOPRESSIN 50 UNITS/NS 500ML DRIP	636	RC						Both			1113	500.85	500.85	1001.7		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	823.62							Fee Schedule																													1001.7							Fee Schedule																																															
VASOPRESSIN ANTIDIURETIC HORMONE 252	301	RC	84588	CPT				Both			183.75	82.69	0.46	165.38	30.17							Fee Schedule		37.71							Fee Schedule		34.96							Fee Schedule		33.94							Fee Schedule		0.49							Fee Schedule		165.38							Fee Schedule		0.56							Fee Schedule		0.46							Fee Schedule		33.94							Fee Schedule		0.56							Fee Schedule		0.46							Fee Schedule		
VASORECTIC 10/25 MG TAB	250	RC	A9270	CPT				Both			2.75	1.24	0.01	2.48	0.01							Fee Schedule		2.04							Fee Schedule																													2.48							Fee Schedule																																															
VASOSTRICT 40 UNITS/100ML PREMIX	636	RC	J2598	CPT				Both			1529.13	688.11	0.5	1376.22		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1131.56							Fee Schedule		0.5							Fee Schedule																				1376.22							Fee Schedule																																															
VAS-Q LIGATION CLIP AN2233	272	RC						Both			77	34.65	31.56	69.3	50.05							Fee Schedule		56.98							Fee Schedule																				33.94							Fee Schedule		69.3							Fee Schedule		39.03							Fee Schedule		31.56							Fee Schedule											39.03							Fee Schedule		31.56							Fee Schedule		
VAXELIS (DIP/PERT/TET/HEPB/POL/HIB) VACC	636	RC	90697	CPT				Both			500.61	225.27	225.27	450.55		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	370.45							Fee Schedule																													450.55							Fee Schedule																																															
VCARE CERVICAL CUP LG 60-6085-202	272	RC						Both			239.4	107.73	0.46	215.46	155.61							Fee Schedule		177.16							Fee Schedule																				0.49							Fee Schedule		215.46							Fee Schedule		0.56							Fee Schedule		0.46							Fee Schedule											0.56							Fee Schedule		0.46							Fee Schedule		
VCARE CERVICAL CUP MED 60-6085-201	272	RC						Both			239.4	107.73	107.73	215.46	155.61							Fee Schedule		177.16							Fee Schedule																													215.46							Fee Schedule																																															
VCARE CERVICAL CUP SM 60-6085-200	272	RC						Both			239.4	107.73	107.73	215.46	155.61							Fee Schedule		177.16							Fee Schedule																													215.46							Fee Schedule																																															
VDRL  CSF ONLY  4128  SPINAL FLUID	302	RC	86592	CPT				Both			45.15	20.32	3.79	40.64	3.79							Fee Schedule		4.75							Fee Schedule		4.4							Fee Schedule		4.27							Fee Schedule											40.64							Fee Schedule																				4.27							Fee Schedule																				
VECURONIUM 10MG/10ML (NORCURON) 10ML	250	RC	A9270	CPT				Both			18.9	8.51	0.01	17.01	0.01							Fee Schedule		13.99							Fee Schedule																													17.01							Fee Schedule																																															
VECURONIUM 20MG/20ML (NORCURON) VIAL	250	RC	A9270	CPT				Both			40.5	18.23	0.01	36.45	0.01							Fee Schedule		29.97							Fee Schedule																													36.45							Fee Schedule																																															
VECURONIUM DRIP (50MG/500ML)	636	RC	A9270	CPT				Both			38	17.1	3.97	34.2		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	28.12							Fee Schedule																				4.27							Fee Schedule		34.2							Fee Schedule		4.91							Fee Schedule		3.97							Fee Schedule											4.91							Fee Schedule		3.97							Fee Schedule		
VEIN STRIPPER #63-4031  (J&J)	272	RC	C1771	CPT				Both			955.5	429.98	87.91	859.95	87.91							Fee Schedule		707.07							Fee Schedule																													859.95							Fee Schedule																																															
VEIN STRIPPER DISP.#634031 (CODMAN)	272	RC						Both			68.25	30.71	30.71	61.43	44.36							Fee Schedule		50.51							Fee Schedule																													61.43							Fee Schedule																																															
VENA CAVA FILTER # 31328 ( B BRAUN INTER	278	RC	C1880	CPT				Both			3595.2	1617.84	1617.84	3235.68		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	2660.45							Fee Schedule																													3235.68							Fee Schedule																																															
VENA CAVA FILTER (B BRAUN INTERVENTION)	278	RC	C1880	CPT				Both			4646.25	2090.81	2090.81	4181.63		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	3438.23							Fee Schedule																													4181.63							Fee Schedule																																															
VENA CAVA FILTER 05010519 BRAUN INTERV.	278	RC	C1880	CPT				Both			2913.75	1311.19	1311.19	2622.38		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	2156.18							Fee Schedule																													2622.38							Fee Schedule																																															
VENA CAVA FILTER( B. BRAUN INTERVENTIONA	278	RC	C1880	CPT				Both			3627.75	1632.49	1632.49	3264.98		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	2684.54							Fee Schedule																													3264.98							Fee Schedule																																															
VENATECH LP 05010024	278	RC	C1880	CPT				Both			4645.2	2090.34	2090.34	4180.68		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	3437.45							Fee Schedule																													4180.68							Fee Schedule																																															
VENIPUNCTURE	300	RC	36415	CPT				Both			19.95	8.98	2.16	17.96	2.16							Fee Schedule		3							Fee Schedule		9.62							Fee Schedule		8.83							Fee Schedule											17.96							Fee Schedule																				8.83							Fee Schedule																				
VENIPUNCTURE < AGE 1	370	RC	36420	CPT				Both			75	33.75	33.75	72.59	72.59							Fee Schedule		55.5							Fee Schedule																													67.5							Fee Schedule																																															
VENIPUNCTURE >AGE 1	370	RC	36425	CPT				Both			84	37.8	37.8	75.6	62.57							Fee Schedule		62.16							Fee Schedule																													75.6							Fee Schedule																																															
VENIPUNCTURE OR IV<3YEARS	370	RC	36400	CPT				Both			80	36	8.69	72	29.33							Fee Schedule		59.2							Fee Schedule																				9.34							Fee Schedule		72							Fee Schedule		10.74							Fee Schedule		8.69							Fee Schedule											10.74							Fee Schedule		8.69							Fee Schedule		
VENIPUNCTURE UNDER ANES 3YRS OR OLDER	370	RC	36410	CPT				Both			32.55	14.65	14.65	29.3	14.65							Fee Schedule		24.09							Fee Schedule											17.81							Fee Schedule											29.3							Fee Schedule																																															
VENIPUNCTURE UNDER ANES LESS THAN 3YRS	370	RC	36406	CPT				Both			32.55	14.65	13.83	29.3	13.83							Fee Schedule		24.09							Fee Schedule											17.81							Fee Schedule											29.3							Fee Schedule																																															
VENLAFAXINE 37.5MG (EFFEXOR) TABLET	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
VENLAFAXINE XR 75MG (EFFEXOR) CAPSULE	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
VENOCAVAGRAM	329	RC	75825	CPT				Both			921.9	414.86	64.51	829.71	64.51							Fee Schedule		68.05							Fee Schedule											356.77							Fee Schedule											829.71							Fee Schedule																				318							Per Diem																				
VENOFER 100 MG/5 ML VIAL	636	RC	J1756	CPT				Both			103.95	46.78	0.23	93.56		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	76.92							Fee Schedule		0.23							Fee Schedule																				93.56							Fee Schedule																																															
VENOFER IV SOLN 20MG/1ML - 10 ML VIAL	636	RC	J1756	CPT				Both			467.58	210.41	0.23	420.82		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	346.01							Fee Schedule		0.23							Fee Schedule																				420.82							Fee Schedule																																															
VENOGRAM UNIL LT	329	RC	75820	CPT				Both			325.5	146.48	26.72	318	66.25							Fee Schedule		70							Fee Schedule											26.72							Fee Schedule											292.95							Fee Schedule																				318							Per Diem																				
VENOGRAM UNIL RT	329	RC	75820	CPT				Both			325.5	146.48	0.21	318	66.25							Fee Schedule		70							Fee Schedule											26.72							Fee Schedule		0.23							Fee Schedule		292.95							Fee Schedule		0.26							Fee Schedule		0.21							Fee Schedule		318							Per Diem		0.26							Fee Schedule		0.21							Fee Schedule		
VENOUS CANNUL TRAY	272	RC						Both			163.8	73.71	0.21	147.42	106.47							Fee Schedule		121.21							Fee Schedule																				0.23							Fee Schedule		147.42							Fee Schedule		0.26							Fee Schedule		0.21							Fee Schedule											0.26							Fee Schedule		0.21							Fee Schedule		
VENT CIRCUIT KIT NEW RT380  ( SENECA )	272	RC						Both			125	56.25	56.25	112.5	81.25							Fee Schedule		92.5							Fee Schedule																													112.5							Fee Schedule																																															
VENT CIRCUIT OLD (OY1778)	272	RC	A4618	CPT				Both			7.35	3.31	3.31	11.1	6.81							Fee Schedule		5.44							Fee Schedule		11.1							Fee Schedule		4.33							Fee Schedule											6.62							Fee Schedule																																															
VENT TUBE STRAIGHT FLUOROPLSTC .045  DAV	272	RC						Both			28.35	12.76	12.76	25.52	18.43							Fee Schedule		20.98							Fee Schedule																													25.52							Fee Schedule																																															
VENTED SPIKE ADAPTER #2C0471 *DISC.*	272	RC						Both			3.15	1.42	1.42	2.84	2.05							Fee Schedule		2.33							Fee Schedule																													2.84							Fee Schedule																																															
VENTI MASK (HUDSON 1088)	272	RC	A4620	CPT				Both			4.2	1.89	0.57	12.4	0.57							Fee Schedule		3.11							Fee Schedule		0.94							Fee Schedule		0.71							Fee Schedule		10.78							Fee Schedule		3.78							Fee Schedule		12.4							Fee Schedule		10.03							Fee Schedule											12.4							Fee Schedule		10.03							Fee Schedule		
VENTILATOR INITIAL	419	RC	94002	CPT				Both			283.5	127.58	70.84	286	175							Per Diem		209.79							Fee Schedule											70.84							Fee Schedule											255.15							Fee Schedule																				286							Case Rate																				
VENTOLIN HFA INHALER (ALBUTEROL SULF)	250	RC	J3535	CPT				Both			82.95	37.33	37.33	74.66	53.92							Fee Schedule		61.38							Fee Schedule																													74.66							Fee Schedule																																															
VENTOLIN ROTOHALER	250	RC	A9270	CPT				Both			78.66	35.4	0.01	70.79	0.01							Fee Schedule		58.21							Fee Schedule																				0.91							Fee Schedule		70.79							Fee Schedule		1.05							Fee Schedule		0.85							Fee Schedule											1.05							Fee Schedule		0.85							Fee Schedule		
VENTSTAR BREATHING CIRCUIT MP00310	272	RC	A4618	CPT				Both			23	10.35	4.33	20.7	6.81							Fee Schedule		17.02							Fee Schedule		11.1							Fee Schedule		4.33							Fee Schedule											20.7							Fee Schedule																																															
VERAPAMIL 120MG SR TABLET	250	RC	A9270	CPT				Both			4.2	1.89	0.01	3.78	0.01							Fee Schedule		3.11							Fee Schedule																													3.78							Fee Schedule																																															
VERAPAMIL 40 MG TABLET UD	250	RC	A9270	CPT				Both			4.2	1.89	0.01	3.78	0.01							Fee Schedule		3.11							Fee Schedule																													3.78							Fee Schedule																																															
VERAPAMIL 5 MG/2ML INJECTION	250	RC	A9270	CPT				Both			112.35	50.56	0.01	101.12	0.01							Fee Schedule		83.14							Fee Schedule																				10.78							Fee Schedule		101.12							Fee Schedule		12.4							Fee Schedule		10.03							Fee Schedule											12.4							Fee Schedule		10.03							Fee Schedule		
VERAPAMIL 5MG	250	RC						Both			3.78	1.7	1.7	3.4	2.46							Fee Schedule		2.8							Fee Schedule																													3.4							Fee Schedule																																															
VERAPAMIL 5MG/2ML VIAL	250	RC	A9270	CPT				Both			7.68	3.46	0.01	6.91	0.01							Fee Schedule		5.68							Fee Schedule																													6.91							Fee Schedule																																															
VERAPAMIL 80MG (ISOPTIN) TABLET	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
VERAPAMIL ER 120MG (ISOPTIN) TABLET	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
VERAPAMIL ER 180MG (ISOPTIN) TABLET	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
VERAPAMIL ER 240MG (ISOPTIN) TABLET	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
VERAPAMIL SR 240 MG CAP	250	RC	A9270	CPT				Both			3.38	1.52	0.01	3.04	0.01							Fee Schedule		2.5							Fee Schedule																													3.04							Fee Schedule																																															
VERSATEL DRESSING 3X4  #MSC1734EPZ	272	RC	A6206	CPT				Both			12	5.4	2.34	10.8	2.34							Fee Schedule		8.88							Fee Schedule																													10.8							Fee Schedule																																															
VERSETTE EXT. CATH. #BLDYND3030M	270	RC	A6590	CPT				Both			28	12.6	12.6	433.84	18.2							Fee Schedule		20.72							Fee Schedule		433.84							Fee Schedule																				25.2							Fee Schedule																																															
VERTESSA LITE Y-MESH CALDERA CAL-VLY2643	278	RC	C1781	CPT				Both			2754	1239.3	1239.3	2478.6		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	2037.96							Fee Schedule																													2478.6							Fee Schedule																																															
VERTICAL DRAPE 5960	270	RC						Both			73.5	33.08	33.08	66.15	47.78							Fee Schedule		54.39							Fee Schedule																													66.15							Fee Schedule																																															
VERY LONG CHAIN FATTY ACIDS 90559	301	RC	82726	CPT				Both			262.5	118.13	16.05	484.38	16.05							Fee Schedule		20.06							Fee Schedule		20.34							Fee Schedule		19.75							Fee Schedule		421.2							Fee Schedule		236.25							Fee Schedule		484.38							Fee Schedule		391.72							Fee Schedule		19.75							Fee Schedule		484.38							Fee Schedule		391.72							Fee Schedule		
VERY MINOR PROCEDURE ROOM	360	RC						Both			1050	472.5	472.5	945	682.5							Fee Schedule		777							Fee Schedule																													945							Fee Schedule																																															
VESSEL CANNULAE VC-110101 (LIVA NOVA)	272	RC						Both			15.75	7.09	7.09	14.18	10.24							Fee Schedule		11.66							Fee Schedule																													14.18							Fee Schedule																																															
VESSEL LOOPS STERION #011012PBX	272	RC						Both			3	1.35	1.35	22.71	1.95							Fee Schedule		2.22							Fee Schedule																				19.75							Fee Schedule		2.7							Fee Schedule		22.71							Fee Schedule		18.37							Fee Schedule											22.71							Fee Schedule		18.37							Fee Schedule		
VESSEL LOOPS STERION 011011PBX	272	RC						Both			6	2.7	2.7	5.4	3.9							Fee Schedule		4.44							Fee Schedule																													5.4							Fee Schedule																																															
VEST RESTRAINT LARGE 3311L	274	RC	E0710	CPT				Both			35	15.75	15.75	31.5		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	25.9							Fee Schedule																													31.5							Fee Schedule																																															
VEST RESTRAINT MEDIUM 3311M	274	RC	E0710	CPT				Both			37	16.65	16.65	33.3		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	27.38							Fee Schedule																													33.3							Fee Schedule																																															
VFC IMMUN ADMIN NASAL/ORAL ADD VAC	771	RC	90474	CPT				Both			20	9	3.13	18	5							Fee Schedule		14.8							Fee Schedule											3.13							Fee Schedule											18							Fee Schedule																																															
"VFC IMMUN ADMIN NASAL/ORAL, 1 VACC"	771	RC	90473	CPT				Both			20	9	3.13	18	5							Fee Schedule		14.8							Fee Schedule											3.13							Fee Schedule											18							Fee Schedule																																															
"VFC IMMUN ADMIN, EA ADDTL VACCINE"	771	RC	90472	CPT				Both			20	9	4.57	18	10							Fee Schedule		14.8							Fee Schedule											4.57							Fee Schedule											18							Fee Schedule																																															
"VFC IMMUN ADMIN, PROPH 1 VACCINE"	771	RC	90471	CPT				Both			20	9	4.47	18	10							Fee Schedule		14.8							Fee Schedule											4.47							Fee Schedule											18							Fee Schedule																																															
VIA CANISTERS VIACAN05	272	RC						Both			117.6	52.92	52.92	105.84	76.44							Fee Schedule		87.02							Fee Schedule																													105.84							Fee Schedule																																															
VIA SPIRAL DRESSING MED VIAGFM05	272	RC						Both			144.9	65.21	65.21	130.41	94.19							Fee Schedule		107.23							Fee Schedule																													130.41							Fee Schedule																																															
VIA SPIRAL DRESSING SM VIAGFS05	272	RC						Both			115.5	51.98	51.98	103.95	75.08							Fee Schedule		85.47							Fee Schedule																													103.95							Fee Schedule																																															
VIA STARTER KIT VIAKIT07S05	272	RC	A6550	CPT				Both			1874.25	843.41	19.58	1686.83	19.58							Fee Schedule		1386.95							Fee Schedule		32.29							Fee Schedule		23.89							Fee Schedule											1686.83							Fee Schedule																																															
VIAGRA 50 MG TABLETS	250	RC	A9270	CPT				Both			26.46	11.91	0.01	23.81	0.01							Fee Schedule		19.58							Fee Schedule																													23.81							Fee Schedule																																															
VIAL ADAPTOR  (BAXTER HEALTHCARE)	258	RC						Both			37.8	17.01	17.01	34.02	24.57							Fee Schedule		27.97							Fee Schedule																													34.02							Fee Schedule																																															
VIBRAMYCIN 100MG (DOXYCYCLINE)	250	RC						Both			11.03	4.96	4.96	36.05	7.17							Fee Schedule		8.16							Fee Schedule																				31.35							Fee Schedule		9.93							Fee Schedule		36.05							Fee Schedule		29.16							Fee Schedule											36.05							Fee Schedule		29.16							Fee Schedule		
VICKS VAPOR RUB	250	RC	A9270	CPT				Both			7.5	3.38	0.01	6.75	0.01							Fee Schedule		5.55							Fee Schedule																													6.75							Fee Schedule																																															
VICON FORTE CAPS.	250	RC	A9270	CPT				Both			1.58	0.71	0.01	1.42	0.01							Fee Schedule		1.17							Fee Schedule																													1.42							Fee Schedule																																															
VICOPROFEN 200/7.5 MG TABLET UD	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
VICRIL MESH DEX II  # 833-213 ( MICROVAS	272	RC						Both			94.5	42.53	42.53	85.05	61.43							Fee Schedule		69.93							Fee Schedule																													85.05							Fee Schedule																																															
VICRYL  EJ10G	272	RC						Both			150	67.5	67.5	135	97.5							Fee Schedule		111							Fee Schedule																													135							Fee Schedule																																															
VICRYL 0 #J364H	272	RC						Both			6	2.7	2.7	5.4	3.9							Fee Schedule		4.44							Fee Schedule																													5.4							Fee Schedule																																															
VICRYL 0 BLUNT TIP J727D	272	RC						Both			43	19.35	19.35	38.7	27.95							Fee Schedule		31.82							Fee Schedule																													38.7							Fee Schedule																																															
VICRYL 0 BLUNT TIP VCPB340H (WAS JB340)	272	RC						Both			7	3.15	3.15	6.3	4.55							Fee Schedule		5.18							Fee Schedule																													6.3							Fee Schedule																																															
VICRYL 0 BLUNT TIP VCPB840D (WAS JB840)	272	RC						Both			54	24.3	24.3	48.6	35.1							Fee Schedule		39.96							Fee Schedule																													48.6							Fee Schedule																																															
VICRYL 0 J267H	272	RC						Both			7.35	3.31	3.31	6.62	4.78							Fee Schedule		5.44							Fee Schedule																													6.62							Fee Schedule																																															
VICRYL 0 J267H	272	RC						Both			6	2.7	2.7	5.4	3.9							Fee Schedule		4.44							Fee Schedule																													5.4							Fee Schedule																																															
VICRYL 0 J318H *DISC*	272	RC						Both			9.45	4.25	4.25	8.51	6.14							Fee Schedule		6.99							Fee Schedule																													8.51							Fee Schedule																																															
VICRYL 0 J334	272	RC						Both			9.45	4.25	4.25	8.51	6.14							Fee Schedule		6.99							Fee Schedule																													8.51							Fee Schedule																																															
VICRYL 0 J334H	272	RC						Both			6	2.7	2.7	5.4	3.9							Fee Schedule		4.44							Fee Schedule																													5.4							Fee Schedule																																															
VICRYL 0 J340H	272	RC						Both			6	2.7	2.7	5.4	3.9							Fee Schedule		4.44							Fee Schedule																													5.4							Fee Schedule																																															
VICRYL 0 J346H	272	RC						Both			6	2.7	2.7	5.4	3.9							Fee Schedule		4.44							Fee Schedule																													5.4							Fee Schedule																																															
VICRYL 0 J376	272	RC						Both			11.55	5.2	5.2	10.4	7.51							Fee Schedule		8.55							Fee Schedule																													10.4							Fee Schedule																																															
VICRYL 0 J381H	272	RC						Both			7	3.15	3.15	6.3	4.55							Fee Schedule		5.18							Fee Schedule																													6.3							Fee Schedule																																															
VICRYL 0 J418H	272	RC						Both			6	2.7	2.7	5.4	3.9							Fee Schedule		4.44							Fee Schedule																													5.4							Fee Schedule																																															
VICRYL 0 J467H	272	RC						Both			6	2.7	2.7	5.4	3.9							Fee Schedule		4.44							Fee Schedule																													5.4							Fee Schedule																																															
VICRYL 0 J636H	272	RC						Both			9	4.05	4.05	8.1	5.85							Fee Schedule		6.66							Fee Schedule																													8.1							Fee Schedule																																															
VICRYL 0 J701D	272	RC						Both			56	25.2	25.2	50.4	36.4							Fee Schedule		41.44							Fee Schedule																													50.4							Fee Schedule																																															
VICRYL 0 J71G	272	RC						Both			71.4	32.13	32.13	64.26	46.41							Fee Schedule		52.84							Fee Schedule																													64.26							Fee Schedule																																															
VICRYL 0 J958H	272	RC						Both			6	2.7	2.7	5.4	3.9							Fee Schedule		4.44							Fee Schedule																													5.4							Fee Schedule																																															
VICRYL 0 J978H	272	RC						Both			6	2.7	2.7	5.4	3.9							Fee Schedule		4.44							Fee Schedule																													5.4							Fee Schedule																																															
VICRYL 0 JTN0G	272	RC						Both			99	44.55	44.55	89.1	64.35							Fee Schedule		73.26							Fee Schedule																													89.1							Fee Schedule																																															
VICRYL 0 VCP270H	272	RC						Both			6	2.7	2.7	5.4	3.9							Fee Schedule		4.44							Fee Schedule																													5.4							Fee Schedule																																															
VICRYL 0 VCP280H ANTIBACTERIAL	272	RC						Both			43.05	19.37	19.37	38.75	27.98							Fee Schedule		31.86							Fee Schedule																													38.75							Fee Schedule																																															
VICRYL 0 VCP376H (DISC J376H)	272	RC						Both			7	3.15	3.15	6.3	4.55							Fee Schedule		5.18							Fee Schedule																													6.3							Fee Schedule																																															
VICRYL 0 VCP603H (WAS J603H)	272	RC						Both			7	3.15	3.15	6.3	4.55							Fee Schedule		5.18							Fee Schedule																													6.3							Fee Schedule																																															
VICRYL 0 VCP608H	272	RC						Both			8	3.6	3.6	7.2	5.2							Fee Schedule		5.92							Fee Schedule																													7.2							Fee Schedule																																															
VICRYL 0 VCPP31D	272	RC						Both			43	19.35	19.35	38.7	27.95							Fee Schedule		31.82							Fee Schedule																													38.7							Fee Schedule																																															
VICRYL 1 #J371H	272	RC						Both			6	2.7	2.7	5.4	3.9							Fee Schedule		4.44							Fee Schedule																													5.4							Fee Schedule																																															
VICRYL 1 BLUNT JB977H *DISC SEE VCPB977H	272	RC						Both			8	3.6	3.6	7.2	5.2							Fee Schedule		5.92							Fee Schedule																													7.2							Fee Schedule																																															
VICRYL 1 BLUNT TIP #VCPB977H	272	RC						Both			8	3.6	3.6	7.2	5.2							Fee Schedule		5.92							Fee Schedule																													7.2							Fee Schedule																																															
VICRYL 1 BLUNT TIP JB841	272	RC						Both			54	24.3	24.3	48.6	35.1							Fee Schedule		39.96							Fee Schedule																													48.6							Fee Schedule																																															
VICRYL 1 BLUNT TIP VCP840D	272	RC						Both			43	19.35	19.35	38.7	27.95							Fee Schedule		31.82							Fee Schedule																													38.7							Fee Schedule																																															
VICRYL 1.0 J357H	272	RC						Both			12.6	5.67	5.67	11.34	8.19							Fee Schedule		9.32							Fee Schedule																													11.34							Fee Schedule																																															
VICRYL 1.0 J535	272	RC						Both			29.4	13.23	13.23	26.46	19.11							Fee Schedule		21.76							Fee Schedule																													26.46							Fee Schedule																																															
VICRYL 1.0 J765D *DISC SEE VCP765D*	272	RC						Both			37	16.65	16.65	33.3	24.05							Fee Schedule		27.38							Fee Schedule																													33.3							Fee Schedule																																															
VICRYL 1.0 J871H	272	RC						Both			9.45	4.25	4.25	8.51	6.14							Fee Schedule		6.99							Fee Schedule																													8.51							Fee Schedule																																															
VICRYL 1.0 VCP757T CONTROL RELEASE	272	RC						Both			18.9	8.51	8.51	17.01	12.29							Fee Schedule		13.99							Fee Schedule																													17.01							Fee Schedule																																															
VICRYL 1-0 J347H	272	RC						Both			6	2.7	2.7	5.4	3.9							Fee Schedule		4.44							Fee Schedule																													5.4							Fee Schedule																																															
VICRYL 1-0 J468H	272	RC						Both			11.55	5.2	5.2	10.4	7.51							Fee Schedule		8.55							Fee Schedule																													10.4							Fee Schedule																																															
VICRYL 1-0 J741D	272	RC						Both			42	18.9	18.9	37.8	27.3							Fee Schedule		31.08							Fee Schedule																													37.8							Fee Schedule																																															
VICRYL 1-0 JJ40G	272	RC						Both			29.4	13.23	13.23	26.46	19.11							Fee Schedule		21.76							Fee Schedule																													26.46							Fee Schedule																																															
VICRYL 1-0 VCP474H	272	RC						Both			11.55	5.2	5.2	10.4	7.51							Fee Schedule		8.55							Fee Schedule																													10.4							Fee Schedule																																															
VICRYL 2.0 D7585	272	RC						Both			490	220.5	220.5	441	318.5							Fee Schedule		362.6							Fee Schedule																													441							Fee Schedule																																															
VICRYL 2.0 J275H	272	RC						Both			5	2.25	2.25	4.5	3.25							Fee Schedule		3.7							Fee Schedule																													4.5							Fee Schedule																																															
VICRYL 2.0 J602H	272	RC						Both			12.6	5.67	5.67	11.34	8.19							Fee Schedule		9.32							Fee Schedule																													11.34							Fee Schedule																																															
VICRYL 2.0 J629H	272	RC						Both			14.7	6.62	6.62	13.23	9.56							Fee Schedule		10.88							Fee Schedule																													13.23							Fee Schedule																																															
VICRYL 2.0 J726D	272	RC						Both			39.9	17.96	17.96	35.91	25.94							Fee Schedule		29.53							Fee Schedule																													35.91							Fee Schedule																																															
VICRYL 2.0 J762D CONTROL RELEASE	272	RC						Both			45	20.25	20.25	40.5	29.25							Fee Schedule		33.3							Fee Schedule																													40.5							Fee Schedule																																															
VICRYL 2.0 J839D	272	RC						Both			36	16.2	16.2	32.4	23.4							Fee Schedule		26.64							Fee Schedule																													32.4							Fee Schedule																																															
VICRYL 2-0  VCP417H	272	RC						Both			4.46	2.01	2.01	4.01	2.9							Fee Schedule		3.3							Fee Schedule																													4.01							Fee Schedule																																															
VICRYL 2-0 BLUNT TIP VCPB839D (WAS JB839	272	RC						Both			53	23.85	23.85	47.7	34.45							Fee Schedule		39.22							Fee Schedule																													47.7							Fee Schedule																																															
VICRYL 2-0 J105T	272	RC						Both			45.15	20.32	20.32	40.64	29.35							Fee Schedule		33.41							Fee Schedule																													40.64							Fee Schedule																																															
VICRYL 2-0 J206G	272	RC						Both			8	3.6	3.6	7.2	5.2							Fee Schedule		5.92							Fee Schedule																													7.2							Fee Schedule																																															
VICRYL 2-0 J206G	272	RC						Both			7	3.15	3.15	6.3	4.55							Fee Schedule		5.18							Fee Schedule																													6.3							Fee Schedule																																															
VICRYL 2-0 J259H	272	RC						Both			5	2.25	2.25	4.5	3.25							Fee Schedule		3.7							Fee Schedule																													4.5							Fee Schedule																																															
VICRYL 2-0 J266H	272	RC						Both			11.55	5.2	5.2	10.4	7.51							Fee Schedule		8.55							Fee Schedule																													10.4							Fee Schedule																																															
VICRYL 2-0 J269H	272	RC						Both			6	2.7	2.7	5.4	3.9							Fee Schedule		4.44							Fee Schedule																													5.4							Fee Schedule																																															
VICRYL 2-0 J306H	272	RC						Both			6	2.7	2.7	5.4	3.9							Fee Schedule		4.44							Fee Schedule																													5.4							Fee Schedule																																															
VICRYL 2-0 J317H	272	RC						Both			6	2.7	2.7	5.4	3.9							Fee Schedule		4.44							Fee Schedule																													5.4							Fee Schedule																																															
VICRYL 2-0 J323H	272	RC						Both			6	2.7	2.7	5.4	3.9							Fee Schedule		4.44							Fee Schedule																													5.4							Fee Schedule																																															
VICRYL 2-0 J339H	272	RC						Both			5	2.25	2.25	4.5	3.25							Fee Schedule		3.7							Fee Schedule																													4.5							Fee Schedule																																															
VICRYL 2-0 J357H	272	RC						Both			9.45	4.25	4.25	8.51	6.14							Fee Schedule		6.99							Fee Schedule																													8.51							Fee Schedule																																															
VICRYL 2-0 J417H	272	RC						Both			5	2.25	2.25	4.5	3.25							Fee Schedule		3.7							Fee Schedule																													4.5							Fee Schedule																																															
VICRYL 2-0 J443H	272	RC						Both			6.3	2.84	2.84	5.67	4.1							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
VICRYL 2-0 J739D	272	RC						Both			43	19.35	19.35	38.7	27.95							Fee Schedule		31.82							Fee Schedule																													38.7							Fee Schedule																																															
VICRYL 2-0 J839H	272	RC						Both			56.7	25.52	25.52	51.03	36.86							Fee Schedule		41.96							Fee Schedule																													51.03							Fee Schedule																																															
VICRYL 2-0 J905T	272	RC						Both			27.3	12.29	12.29	24.57	17.75							Fee Schedule		20.2							Fee Schedule																													24.57							Fee Schedule																																															
VICRYL 2-0 J945H	272	RC						Both			6	2.7	2.7	5.4	3.9							Fee Schedule		4.44							Fee Schedule																													5.4							Fee Schedule																																															
VICRYL 2-0 J945H	272	RC						Both			6	2.7	2.7	5.4	3.9							Fee Schedule		4.44							Fee Schedule																													5.4							Fee Schedule																																															
VICRYL 2-0 JJ82G	272	RC						Both			85.05	38.27	38.27	76.55	55.28							Fee Schedule		62.94							Fee Schedule																													76.55							Fee Schedule																																															
VICRYL 2-0 PLUS CT-1 VCP839D	272	RC						Both			43	19.35	19.35	38.7	27.95							Fee Schedule		31.82							Fee Schedule																													38.7							Fee Schedule																																															
VICRYL 3.0 J104T	272	RC						Both			23.1	10.4	10.4	20.79	15.02							Fee Schedule		17.09							Fee Schedule																													20.79							Fee Schedule																																															
VICRYL 3.0 J205	272	RC						Both			7	3.15	3.15	6.3	4.55							Fee Schedule		5.18							Fee Schedule																													6.3							Fee Schedule																																															
VICRYL 3.0 J305H	272	RC						Both			6	2.7	2.7	5.4	3.9							Fee Schedule		4.44							Fee Schedule																													5.4							Fee Schedule																																															
VICRYL 3.0 J423H *DISC SEE VCP423H*	272	RC						Both			24	10.8	10.8	21.6	15.6							Fee Schedule		17.76							Fee Schedule																													21.6							Fee Schedule																																															
VICRYL 3.0 J471	272	RC						Both			11.55	5.2	5.2	10.4	7.51							Fee Schedule		8.55							Fee Schedule																													10.4							Fee Schedule																																															
VICRYL 3.0 J904T	272	RC						Both			25.2	11.34	11.34	22.68	16.38							Fee Schedule		18.65							Fee Schedule																													22.68							Fee Schedule																																															
VICRYL 3.0 VCP784D	272	RC						Both			42	18.9	18.9	37.8	27.3							Fee Schedule		31.08							Fee Schedule																													37.8							Fee Schedule																																															
VICRYL 3-0 #J774D	272	RC						Both			37	16.65	16.65	33.3	24.05							Fee Schedule		27.38							Fee Schedule																													33.3							Fee Schedule																																															
VICRYL 3-0 471H	272	RC						Both			12.6	5.67	5.67	11.34	8.19							Fee Schedule		9.32							Fee Schedule																													11.34							Fee Schedule																																															
VICRYL 3-0 ANTIBACT. VCPB864D	272	RC						Both			112.35	50.56	50.56	101.12	73.03							Fee Schedule		83.14							Fee Schedule																													101.12							Fee Schedule																																															
VICRYL 3-0 BLUNT TIP VCPB341(JB341 DISC)	272	RC						Both			7	3.15	3.15	6.3	4.55							Fee Schedule		5.18							Fee Schedule																													6.3							Fee Schedule																																															
VICRYL 3-0 J258H	272	RC						Both			5	2.25	2.25	4.5	3.25							Fee Schedule		3.7							Fee Schedule																													4.5							Fee Schedule																																															
VICRYL 3-0 J285G	272	RC						Both			8	3.6	3.6	7.2	5.2							Fee Schedule		5.92							Fee Schedule																													7.2							Fee Schedule																																															
VICRYL 3-0 J316H	272	RC						Both			6	2.7	2.7	5.4	3.9							Fee Schedule		4.44							Fee Schedule																													5.4							Fee Schedule																																															
VICRYL 3-0 J316H	272	RC						Both			6	2.7	2.7	5.4	3.9							Fee Schedule		4.44							Fee Schedule																													5.4							Fee Schedule																																															
VICRYL 3-0 J316H	272	RC						Both			5	2.25	2.25	4.5	3.25							Fee Schedule		3.7							Fee Schedule																													4.5							Fee Schedule																																															
VICRYL 3-0 J338H	272	RC						Both			5	2.25	2.25	4.5	3.25							Fee Schedule		3.7							Fee Schedule																													4.5							Fee Schedule																																															
VICRYL 3-0 J427H	272	RC						Both			13.65	6.14	6.14	12.29	8.87							Fee Schedule		10.1							Fee Schedule																													12.29							Fee Schedule																																															
VICRYL 3-0 J663H	272	RC						Both			7	3.15	3.15	6.3	4.55							Fee Schedule		5.18							Fee Schedule																													6.3							Fee Schedule																																															
VICRYL 3-0 J944H	272	RC						Both			6	2.7	2.7	5.4	3.9							Fee Schedule		4.44							Fee Schedule																													5.4							Fee Schedule																																															
VICRYL 3-0 VCP205G (WAS J205G)	272	RC						Both			8	3.6	3.6	7.2	5.2							Fee Schedule		5.92							Fee Schedule																													7.2							Fee Schedule																																															
VICRYL 3-0 VCP416H (WAS J416H)	272	RC						Both			6	2.7	2.7	5.4	3.9							Fee Schedule		4.44							Fee Schedule																													5.4							Fee Schedule																																															
VICRYL 3-0 VCP423H	272	RC						Both			8	3.6	3.6	7.2	5.2							Fee Schedule		5.92							Fee Schedule																													7.2							Fee Schedule																																															
VICRYL 3-0 VCP442H (WAS J442H)	272	RC						Both			8	3.6	3.6	7.2	5.2							Fee Schedule		5.92							Fee Schedule																													7.2							Fee Schedule																																															
VICRYL 4.0 (J422H DISC) VCP936H	272	RC						Both			17	7.65	7.65	15.3	11.05							Fee Schedule		12.58							Fee Schedule																													15.3							Fee Schedule																																															
VICRYL 4.0 J434H	272	RC						Both			6.33	2.85	2.85	5.7	4.11							Fee Schedule		4.68							Fee Schedule																													5.7							Fee Schedule																																															
VICRYL 4.0 VCP493G	272	RC						Both			10.5	4.73	4.73	9.45	6.83							Fee Schedule		7.77							Fee Schedule																													9.45							Fee Schedule																																															
VICRYL 4.0 VCP503G	272	RC						Both			20	9	9	18	13							Fee Schedule		14.8							Fee Schedule																													18							Fee Schedule																																															
VICRYL 4-0 J304H	272	RC						Both			6	2.7	2.7	5.4	3.9							Fee Schedule		4.44							Fee Schedule																													5.4							Fee Schedule																																															
VICRYL 4-0 J310H	272	RC						Both			7.35	3.31	3.31	6.62	4.78							Fee Schedule		5.44							Fee Schedule																													6.62							Fee Schedule																																															
VICRYL 4-0 J415H	272	RC						Both			6	2.7	2.7	5.4	3.9							Fee Schedule		4.44							Fee Schedule																													5.4							Fee Schedule																																															
VICRYL 4-0 J422H *DISC. SEE VCP936H*	272	RC						Both			8	3.6	3.6	7.2	5.2							Fee Schedule		5.92							Fee Schedule																													7.2							Fee Schedule																																															
VICRYL 4-0 J434H	272	RC						Both			6.3	2.84	2.84	5.67	4.1							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
VICRYL 4-0 J494G	272	RC						Both			15	6.75	6.75	13.5	9.75							Fee Schedule		11.1							Fee Schedule																													13.5							Fee Schedule																																															
VICRYL 4-0 J496G	272	RC						Both			13.65	6.14	6.14	12.29	8.87							Fee Schedule		10.1							Fee Schedule																													12.29							Fee Schedule																																															
VICRYL 4-0 J496H	272	RC						Both			15	6.75	6.75	13.5	9.75							Fee Schedule		11.1							Fee Schedule																													13.5							Fee Schedule																																															
VICRYL 4-0 J662H	272	RC						Both			7	3.15	3.15	6.3	4.55							Fee Schedule		5.18							Fee Schedule																													6.3							Fee Schedule																																															
VICRYL 4-0 PSII VCP496ZH (OLD# VCP496H)	272	RC						Both			16	7.2	7.2	14.4	10.4							Fee Schedule		11.84							Fee Schedule																													14.4							Fee Schedule																																															
VICRYL 4-0 VCP504G	272	RC						Both			19	8.55	8.55	17.1	12.35							Fee Schedule		14.06							Fee Schedule																													17.1							Fee Schedule																																															
VICRYL 4-0 VCP504G (WAS J504G)	272	RC						Both			19	8.55	8.55	17.1	12.35							Fee Schedule		14.06							Fee Schedule																													17.1							Fee Schedule																																															
VICRYL 4-0 VCP714D (WAS J714D)	272	RC						Both			50	22.5	22.5	45	32.5							Fee Schedule		37							Fee Schedule																													45							Fee Schedule																																															
VICRYL 5 J503G *DISC SEE VCP503G*	272	RC						Both			17.85	8.03	8.03	16.07	11.6							Fee Schedule		13.21							Fee Schedule																													16.07							Fee Schedule																																															
VICRYL 5.0 J571G	272	RC						Both			49.35	22.21	22.21	44.42	32.08							Fee Schedule		36.52							Fee Schedule																													44.42							Fee Schedule																																															
VICRYL 5-0 J463G	272	RC						Both			17	7.65	7.65	15.3	11.05							Fee Schedule		12.58							Fee Schedule																													15.3							Fee Schedule																																															
VICRYL 5-0 J463G	272	RC						Both			15	6.75	6.75	13.5	9.75							Fee Schedule		11.1							Fee Schedule																													13.5							Fee Schedule																																															
VICRYL 5-0 J844G	272	RC						Both			21	9.45	9.45	18.9	13.65							Fee Schedule		15.54							Fee Schedule																													18.9							Fee Schedule																																															
VICRYL 6-0 J570G	272	RC						Both			54	24.3	24.3	48.6	35.1							Fee Schedule		39.96							Fee Schedule																													48.6							Fee Schedule																																															
VICRYL ER CHARGE	272	RC						Both			18.9	8.51	8.51	17.01	12.29							Fee Schedule		13.99							Fee Schedule																													17.01							Fee Schedule																																															
VICRYL J347 OB	272	RC						Both			12.6	5.67	5.67	11.34	8.19							Fee Schedule		9.32							Fee Schedule																													11.34							Fee Schedule																																															
VICRYL J461	272	RC						Both			11.55	5.2	5.2	10.4	7.51							Fee Schedule		8.55							Fee Schedule																													10.4							Fee Schedule																																															
VICRYL J467H	272	RC						Both			21	9.45	9.45	18.9	13.65							Fee Schedule		15.54							Fee Schedule																													18.9							Fee Schedule																																															
VICRYL J468H	272	RC						Both			10.5	4.73	4.73	9.45	6.83							Fee Schedule		7.77							Fee Schedule																													9.45							Fee Schedule																																															
VICRYL J602H	270	RC						Both			11.55	5.2	5.2	10.4	7.51							Fee Schedule		8.55							Fee Schedule																													10.4							Fee Schedule																																															
VICRYL J869H	272	RC						Both			9.45	4.25	4.25	8.51	6.14							Fee Schedule		6.99							Fee Schedule																													8.51							Fee Schedule																																															
VICRYL O JPNG	272	RC						Both			68.25	30.71	30.71	61.43	44.36							Fee Schedule		50.51							Fee Schedule																													61.43							Fee Schedule																																															
VICRYL PLUS 1 CR SUTURE VCP765D	272	RC						Both			43	19.35	19.35	38.7	27.95							Fee Schedule		31.82							Fee Schedule																													38.7							Fee Schedule																																															
VICRYL RAPIDE 3.0 VR944	272	RC						Both			10.5	4.73	4.73	9.45	6.83							Fee Schedule		7.77							Fee Schedule																													9.45							Fee Schedule																																															
VICRYL RAPIDE 3-0 VR416	272	RC						Both			11	4.95	4.95	9.9	7.15							Fee Schedule		8.14							Fee Schedule																													9.9							Fee Schedule																																															
VICRYL RAPIDE 4.0 VR214	272	RC						Both			8.4	3.78	3.78	7.56	5.46							Fee Schedule		6.22							Fee Schedule																													7.56							Fee Schedule																																															
VICRYL REEL 0 J207G	272	RC						Both			14.7	6.62	6.62	13.23	9.56							Fee Schedule		10.88							Fee Schedule																													13.23							Fee Schedule																																															
VIMPAT 100MG (LACOSAMIDE) TABLET	250	RC	A9270	CPT				Both			52.5	23.63	0.01	47.25	0.01							Fee Schedule		38.85							Fee Schedule																													47.25							Fee Schedule																																															
VIOKASE POWDER 67.2/280/280 UNITS/TSP	250	RC	A9270	CPT				Both			7.35	3.31	0.01	6.62	0.01							Fee Schedule		5.44							Fee Schedule																													6.62							Fee Schedule																																															
VIOKASE TABS	250	RC	A9270	CPT				Both			5.25	2.36	0.01	4.73	0.01							Fee Schedule		3.89							Fee Schedule																													4.73							Fee Schedule																																															
VIOXX 25 MG TABLET	250	RC	A9270	CPT				Both			8.93	4.02	0.01	8.04	0.01							Fee Schedule		6.61							Fee Schedule																													8.04							Fee Schedule																																															
VIPER TRAK RADIOPAQUE TAPE VPR-TRKMM	272	RC						Both			453.6	204.12	204.12	408.24	294.84							Fee Schedule		335.66							Fee Schedule																													408.24							Fee Schedule																																															
VIPERSLIDE LUBRICANT VPR-SLD2	272	RC						Both			285	128.25	128.25	256.5	185.25							Fee Schedule		210.9							Fee Schedule																													256.5							Fee Schedule																																															
VIPERTRAK RADIOPAQ GUIDEWIRE VPRTRKMM20	272	RC	C1769	CPT				Both			444	199.8	154.26	399.6	154.26							Fee Schedule		328.56							Fee Schedule																													399.6							Fee Schedule																																															
VIPERTRAK RADIOPAQUE TAPE VPR-TRK	272	RC						Both			600	270	270	540	390							Fee Schedule		444							Fee Schedule																													540							Fee Schedule																																															
VIRACEPT (NELFINAVIR MESY) 625 MG TABLET	250	RC	A9270	CPT				Both			22.05	9.92	0.01	19.85	0.01							Fee Schedule		16.32							Fee Schedule																													19.85							Fee Schedule																																															
VIRAL CULTURE VIR ID 689	306	RC	87252	CPT				Both			149.1	67.1	23.17	134.19	23.17							Fee Schedule		28.97							Fee Schedule		26.85							Fee Schedule		26.07							Fee Schedule											134.19							Fee Schedule																				26.07							Fee Schedule																				
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOS					988	DRG		Inpatient			55486.93	24969.12	24969.12	24969.12							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback				9029.51	9029.51	9029.51	1 through 10									0		No services provided during 15 month lookback period	
VISCOHEEL SOFTSPOT	270	RC	L3485	CPT				Both			91.35	41.11	6.12	82.22	6.12							Fee Schedule		67.6							Fee Schedule																													82.22							Fee Schedule																																															
VISCOSITY 918 SERUM	305	RC	85810	CPT				Both			88.2	39.69	10.38	79.38	10.38							Fee Schedule		12.97							Fee Schedule		12.02							Fee Schedule		11.67							Fee Schedule		26.07							Fee Schedule		79.38							Fee Schedule		29.98							Fee Schedule		24.25							Fee Schedule		11.67							Fee Schedule		29.98							Fee Schedule		24.25							Fee Schedule		
VISICOL 1.5 GM TABLET UD	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
VISIPAQUE 270-150 ML	254	RC	Q9967	CPT				Both			165	74.25	0.12	148.5	0.12							Fee Schedule		122.1							Fee Schedule		0.16							Fee Schedule																				148.5							Fee Schedule																																															
VISIPAQUE 270-50 ML	254	RC	Q9967	CPT				Both			175.14	78.81	0.12	157.63	0.12							Fee Schedule		129.6							Fee Schedule		0.16							Fee Schedule											11.67							Fee Schedule		157.63							Fee Schedule		13.42							Fee Schedule		10.85							Fee Schedule											13.42							Fee Schedule		10.85							Fee Schedule		
VISTARIL 25 MG (HYDROXYZINE PAMOATE) CAP	250	RC	A9270	CPT				Both			2.1	0.95	0.01	1.89	0.01							Fee Schedule		1.55							Fee Schedule																													1.89							Fee Schedule																																															
VISUAL ACUITY SCREEN	471	RC	99173	CPT				Both			30	13.5	0.14	199	2.73							Fee Schedule		22.2							Fee Schedule																				0.16							Fee Schedule		27							Fee Schedule		0.18							Fee Schedule		0.14							Fee Schedule		199							Per Diem		0.18							Fee Schedule		0.14							Fee Schedule		
"VIT B2 36399 PROTECT LIGHT, RED 1ML FZ"	301	RC	84252	CPT				Both			233.1	104.9	0.14	209.79	17.99							Fee Schedule		22.49							Fee Schedule		20.85							Fee Schedule		20.24							Fee Schedule		0.16							Fee Schedule		209.79							Fee Schedule		0.18							Fee Schedule		0.14							Fee Schedule		20.24							Fee Schedule		0.18							Fee Schedule		0.14							Fee Schedule		
VIT K ( IVPB ) 10 MG/NS 50ML    *ADULT*	636	RC	J3430	CPT				Both			174.3	78.44	3.02	156.87		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	128.98							Fee Schedule		3.35							Fee Schedule		3.02							Fee Schedule											156.87							Fee Schedule																																															
VIT K 10MG/ML (PHYTONADIONE) INJ ADULT	636	RC	J3430	CPT				Both			166.95	75.13	3.02	150.26		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	123.54							Fee Schedule		3.35							Fee Schedule		3.02							Fee Schedule											150.26							Fee Schedule																																															
VIT K 1MG/0.5 ML (PHYTONADIONE) NEONATAL	636	RC	J3430	CPT				Both			15.75	7.09	3.02	23.28		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	11.66							Fee Schedule		3.35							Fee Schedule		3.02							Fee Schedule		20.24							Fee Schedule		14.18							Fee Schedule		23.28							Fee Schedule		18.82							Fee Schedule											23.28							Fee Schedule		18.82							Fee Schedule		
VITA DROPS WITH IRON(POLY-VI-SOL)-50ML	250	RC	A9270	CPT				Both			27.3	12.29	0.01	24.57	0.01							Fee Schedule		20.2							Fee Schedule																				3.25							Fee Schedule		24.57							Fee Schedule		3.74							Fee Schedule		3.03							Fee Schedule											3.74							Fee Schedule		3.03							Fee Schedule		
VITA-DROPS W/IRON DROPS-50ML	250	RC	A9270	CPT				Both			27.3	12.29	0.01	24.57	0.01							Fee Schedule		20.2							Fee Schedule																				3.25							Fee Schedule		24.57							Fee Schedule		3.74							Fee Schedule		3.03							Fee Schedule											3.74							Fee Schedule		3.03							Fee Schedule		
VITAL 1.0 CAL RTH 1000ML	250	RC	B4153	CPT				Both			48.3	21.74	0.67	43.47	0.67							Fee Schedule		35.74							Fee Schedule											2.35							Fee Schedule		3.25							Fee Schedule		43.47							Fee Schedule		3.74							Fee Schedule		3.03							Fee Schedule											3.74							Fee Schedule		3.03							Fee Schedule		
VITAL 1.5 CAL RTH 1000ML	250	RC	B4153	CPT				Both			48.3	21.74	0.67	43.47	0.67							Fee Schedule		35.74							Fee Schedule											2.35							Fee Schedule											43.47							Fee Schedule																																															
VITAL 1.5 CAL/ML (240ML CAN)	250	RC	B4153	CPT				Both			22.46	10.11	0.67	20.21	0.67							Fee Schedule		16.62							Fee Schedule											2.35							Fee Schedule											20.21							Fee Schedule																																															
VITAL AF 1.2 CAL RTH 1000ML	250	RC	B4153	CPT				Both			48.3	21.74	0.67	43.47	0.67							Fee Schedule		35.74							Fee Schedule											2.35							Fee Schedule											43.47							Fee Schedule																																															
VITAL AF 1.2 CAL/ML (237ML)	250	RC	B4153	CPT				Both			23.25	10.46	0.67	20.93	0.67							Fee Schedule		17.21							Fee Schedule											2.35							Fee Schedule											20.93							Fee Schedule																																															
VITAL HN TUBE FEEDING	250	RC	B4153	CPT				Both			37.3	16.79	0.67	33.57	0.67							Fee Schedule		27.6							Fee Schedule											2.35							Fee Schedule											33.57							Fee Schedule																																															
VITAL HP 1.0 CAL RTH 1000ML	250	RC	B4153	CPT				Both			95	42.75	0.67	85.5	0.67							Fee Schedule		70.3							Fee Schedule											2.35							Fee Schedule											85.5							Fee Schedule																																															
VITAL SIGN MASK ADULT 6860	271	RC						Both			7	3.15	3.15	6.3	4.55							Fee Schedule		5.18							Fee Schedule																													6.3							Fee Schedule																																															
VITAMIN A & VITAMIN D OINTMENT 42.5GM	250	RC	A9270	CPT				Both			29.97	13.49	0.01	26.97	0.01							Fee Schedule		22.18							Fee Schedule																													26.97							Fee Schedule																																															
"VITAMIN A 10,000 INT UNITS (3000 MCG)"	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
VITAMIN A 921 SERUM REF	301	RC	84590	CPT				Both			112.35	50.56	10.32	101.12	10.32							Fee Schedule		12.9							Fee Schedule		11.96							Fee Schedule		11.61							Fee Schedule											101.12							Fee Schedule																				11.61							Fee Schedule																				
VITAMIN B-1 100MG  (THIAMINE) TABLET	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
VITAMIN B-12 500MCG (CYANOCOBALAMIN) TAB	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
VITAMIN B3  91029  2ML SER FRZ	301	RC	84591	CPT				Both			199.5	89.78	10.8	179.55	12.28							Fee Schedule		17.06							Fee Schedule		17.57							Fee Schedule		17.06							Fee Schedule		11.61							Fee Schedule		179.55							Fee Schedule		13.35							Fee Schedule		10.8							Fee Schedule		17.06							Fee Schedule		13.35							Fee Schedule		10.8							Fee Schedule		
VITAMIN B5 (PANTOTHENIC ACID) 91030	301	RC	84591	CPT				Both			225	101.25	12.28	202.5	12.28							Fee Schedule		17.06							Fee Schedule		17.57							Fee Schedule		17.06							Fee Schedule											202.5							Fee Schedule																				17.06							Fee Schedule																				
VITAMIN B-6  50 MG (PYRIDOXINE) TABLET	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
VITAMIN C  929  ASCORBIC ACID SER FRZ	301	RC	82180	CPT				Both			155.4	69.93	8.78	139.86	8.78							Fee Schedule		10.98							Fee Schedule		10.19							Fee Schedule		9.89							Fee Schedule		17.06							Fee Schedule		139.86							Fee Schedule		19.62							Fee Schedule		15.87							Fee Schedule		9.89							Fee Schedule		19.62							Fee Schedule		15.87							Fee Schedule		
VITAMIN C 500MG (ASCORBIC ACID) TABLET	250	RC	A9270	CPT				Both			6.3	2.84	0.01	19.62	0.01							Fee Schedule		4.66							Fee Schedule																				17.06							Fee Schedule		5.67							Fee Schedule		19.62							Fee Schedule		15.87							Fee Schedule											19.62							Fee Schedule		15.87							Fee Schedule		
VITAMIN D 17306   25 HYDROXY 1ML SERUM	301	RC	82306	CPT				Both			162.75	73.24	26.32	146.48	26.32							Fee Schedule		32.89							Fee Schedule		30.49							Fee Schedule		29.6							Fee Schedule											146.48							Fee Schedule																				29.6							Fee Schedule																				
"VITAMIN D-2  1.25 MG CAP (50,000 UNITS)"	250	RC	A9270	CPT				Both			6.3	2.84	0.01	11.37	0.01							Fee Schedule		4.66							Fee Schedule																				9.89							Fee Schedule		5.67							Fee Schedule		11.37							Fee Schedule		9.2							Fee Schedule											11.37							Fee Schedule		9.2							Fee Schedule		
VITAMIN D-3  400 INTERNATIONAL UNITS TAB	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
VITAMIN D-3 1000 INT UNITS (25MCG) TAB	250	RC	A9270	CPT				Both			6.3	2.84	0.01	34.04	0.01							Fee Schedule		4.66							Fee Schedule																				29.6							Fee Schedule		5.67							Fee Schedule		34.04							Fee Schedule		27.53							Fee Schedule											34.04							Fee Schedule		27.53							Fee Schedule		
VITAMIN E 200IU CAPSULE	250	RC	A9270	CPT				Both			4.2	1.89	0.01	3.78	0.01							Fee Schedule		3.11							Fee Schedule																													3.78							Fee Schedule																																															
VITAMIN E 400 INTERNATIONAL UNIT CAPSULE	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
VITAMIN E EMOILLENT CREAM/OIL 60ML	250	RC	A9270	CPT				Both			24.15	10.87	0.01	21.74	0.01							Fee Schedule		17.87							Fee Schedule																													21.74							Fee Schedule																																															
VITAMIN E OIL	250	RC	A9270	CPT				Both			22.05	9.92	0.01	19.85	0.01							Fee Schedule		16.32							Fee Schedule																													19.85							Fee Schedule																																															
VITAMIN E TOCOPHEROL 931 SERUM REF	301	RC	84446	CPT				Both			206.85	93.08	12.61	186.17	12.61							Fee Schedule		15.75							Fee Schedule		14.61							Fee Schedule		14.18							Fee Schedule											186.17							Fee Schedule																				14.18							Fee Schedule																				
VITAMIN K 36585 4ML PLASMA FRZ	301	RC	84597	CPT				Both			155.4	69.93	12.2	139.86	12.2							Fee Schedule		15.24							Fee Schedule		14.13							Fee Schedule		13.72							Fee Schedule											139.86							Fee Schedule																				13.72							Fee Schedule																				
VITRON-C TABLET UD	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
VIVONEX T.E.N. TUBE FEEDING	250	RC	B4153	CPT				Both			31.5	14.18	0.67	28.35	0.67							Fee Schedule		23.31							Fee Schedule											2.35							Fee Schedule		14.18							Fee Schedule		28.35							Fee Schedule		16.31							Fee Schedule		13.19							Fee Schedule											16.31							Fee Schedule		13.19							Fee Schedule		
V-MASK 8150 (SENECA)	271	RC						Both			7	3.15	3.15	15.78	4.55							Fee Schedule		5.18							Fee Schedule																				13.72							Fee Schedule		6.3							Fee Schedule		15.78							Fee Schedule		12.76							Fee Schedule											15.78							Fee Schedule		12.76							Fee Schedule		
V-MASK PEDIATRIC 301-192 SUB FOR 3227-EE	271	RC						Both			7	3.15	3.15	6.3	4.55							Fee Schedule		5.18							Fee Schedule																													6.3							Fee Schedule																																															
Volar Bilateral 2  ORTHO GLASS	274	RC	A4590	CPT				Both			428.4	192.78	24.09	385.56		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	317.02							Fee Schedule											24.09							Fee Schedule											385.56							Fee Schedule																																															
Volar Bilateral 3  ORTHO GLASS	274	RC	A4590	CPT				Both			535.5	240.98	24.09	481.95		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	396.27							Fee Schedule											24.09							Fee Schedule											481.95							Fee Schedule																																															
Volar Bilateral 4  ORTHO GLASS	270	RC						Both			642.6	289.17	289.17	578.34	417.69							Fee Schedule		475.52							Fee Schedule																													578.34							Fee Schedule																																															
Volar Bilateral 5  ORTHO GLASS	274	RC	A4590	CPT				Both			749.7	337.37	24.09	674.73		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	554.78							Fee Schedule											24.09							Fee Schedule											674.73							Fee Schedule																																															
VOLAR SPLINT R AND L 2  ORTHO GLASS	270	RC						Both			214.2	96.39	96.39	192.78	139.23							Fee Schedule		158.51							Fee Schedule																													192.78							Fee Schedule																																															
VOLAR SPLINT R AND L 3  ORTHO GLASS	271	RC	A4590	CPT				Both			267.75	120.49	20.24	240.98	20.24							Fee Schedule		198.14							Fee Schedule											24.09							Fee Schedule											240.98							Fee Schedule																																															
VOLAR SPLINT R AND L 4  ORTHO GLASS	274	RC						Both			321.3	144.59	144.59	289.17		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	237.76							Fee Schedule																													289.17							Fee Schedule																																															
VOLAR SPLINT R AND L 5  ORTHO GLASS	274	RC	A4590	CPT				Both			374.85	168.68	24.09	337.37		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	277.39							Fee Schedule											24.09							Fee Schedule											337.37							Fee Schedule																																															
VOLATILES 7240  BLOOD	301	RC	84600	CPT				Both			80.85	36.38	14.29	72.77	14.29							Fee Schedule		17.87							Fee Schedule		17.62							Fee Schedule		17.11							Fee Schedule											72.77							Fee Schedule																				17.11							Fee Schedule																				
VOLTAREN 0.1% OPTH.SOL.5ML	250	RC	A9270	CPT				Both			109.2	49.14	0.01	98.28	0.01							Fee Schedule		80.81							Fee Schedule																													98.28							Fee Schedule																																															
VOL-U FEEDER	271	RC						Both			3.15	1.42	1.42	2.84	2.05							Fee Schedule		2.33							Fee Schedule																													2.84							Fee Schedule																																															
VON WILLEBRAND FACTOR ANTIGEN 4919 SPE	305	RC	85246	CPT				Both			202.65	91.19	15.91	182.39	20.39							Fee Schedule		25.49							Fee Schedule		23.63							Fee Schedule		22.94							Fee Schedule		17.11							Fee Schedule		182.39							Fee Schedule		19.68							Fee Schedule		15.91							Fee Schedule		22.94							Fee Schedule		19.68							Fee Schedule		15.91							Fee Schedule		
VON WILLEBRAND MULTIMERIC 5168 SPECIAL	305	RC	85247	CPT				Both			350.7	157.82	20.39	315.63	20.39							Fee Schedule		25.49							Fee Schedule		23.63							Fee Schedule		22.94							Fee Schedule											315.63							Fee Schedule																				22.94							Fee Schedule																				
VORICONAZOLE 200MG TABLET	250	RC	A9270	CPT				Both			140.73	63.33	0.01	126.66	0.01							Fee Schedule		104.14							Fee Schedule																													126.66							Fee Schedule																																															
VORICONAZOLE 94096 2ML SERUM FROZEN	301	RC	80299	CPT				Both			258.3	116.24	13.42	232.47	13.42							Fee Schedule		18.64							Fee Schedule		19.2							Fee Schedule		18.64							Fee Schedule		22.94							Fee Schedule		232.47							Fee Schedule		26.38							Fee Schedule		21.33							Fee Schedule		18.64							Fee Schedule		26.38							Fee Schedule		21.33							Fee Schedule		
VULCAN HOOK ABLATOR #7209646	272	RC						Both			492.45	221.6	21.33	443.21	320.09							Fee Schedule		364.41							Fee Schedule																				22.94							Fee Schedule		443.21							Fee Schedule		26.38							Fee Schedule		21.33							Fee Schedule											26.38							Fee Schedule		21.33							Fee Schedule		
VYEPTI 100MG/ML SDV	636	RC	J3032	CPT				Both			6580.2	2961.09	20.54	5922.18		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	20.54							Fee Schedule		21.12							Fee Schedule																				5922.18							Fee Schedule																																															
VYEPTI 100MG/NS 100ML IVPB	636	RC	J3032	CPT				Both			6580.2	2961.09	17.34	5922.18		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	20.54							Fee Schedule		21.12							Fee Schedule											18.64							Fee Schedule		5922.18							Fee Schedule		21.44							Fee Schedule		17.34							Fee Schedule											21.44							Fee Schedule		17.34							Fee Schedule		
WALKER ADULT FOLD. ADJ. ( REAR CASTERS )	270	RC	E0143	CPT				Both			99	44.55	33.29	89.1	33.29							Fee Schedule		73.26							Fee Schedule		62.72							Fee Schedule																				89.1							Fee Schedule																																															
WALKER- HEMI	270	RC						Both			96.6	43.47	19.07	86.94	62.79							Fee Schedule		71.48							Fee Schedule																				20.5							Fee Schedule		86.94							Fee Schedule		23.58							Fee Schedule		19.07							Fee Schedule											23.58							Fee Schedule		19.07							Fee Schedule		
WALLACH PAPETTE CELL COLLECTOR #908001	272	RC						Both			1	0.45	0.45	23.58	0.65							Fee Schedule		0.74							Fee Schedule																				20.5							Fee Schedule		0.9							Fee Schedule		23.58							Fee Schedule		19.07							Fee Schedule											23.58							Fee Schedule		19.07							Fee Schedule		
WALLFLEX BILIARY STENT #M00570370	278	RC	C1874	CPT				Both			7945	3575.25	56.63	7150.5		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	5879.3							Fee Schedule																				60.89							Fee Schedule		7150.5							Fee Schedule		70.02							Fee Schedule		56.63							Fee Schedule											70.02							Fee Schedule		56.63							Fee Schedule		
WALLFLEX BILIARY STENT #M00570380	278	RC	C1874	CPT				Both			7945	3575.25	3575.25	7150.5		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	5879.3							Fee Schedule																													7150.5							Fee Schedule																																															
WALLFLEX BILIARY STENT #M00570710	278	RC	C1877	CPT				Both			7898	3554.1	3554.1	7108.2		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	5844.52							Fee Schedule																													7108.2							Fee Schedule																																															
WALLFLEX BILIARY STENT #M00570740	278	RC	C1874	CPT				Both			7898	3554.1	3554.1	7108.2		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	5844.52							Fee Schedule																													7108.2							Fee Schedule																																															
WALLFLEX BILIARY STENT M00553660	278	RC	C1874	CPT				Both			15584	7012.8	7012.8	14025.6		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	11532.16							Fee Schedule																													14025.6							Fee Schedule																																															
WALLFLEX BILIARY STENT METAL #M00570360	278	RC	C1874	CPT				Both			7945	3575.25	3575.25	7150.5		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	5879.3							Fee Schedule																													7150.5							Fee Schedule																																															
WALLFLEX BILIARY STENT METAL #M00570380	278	RC	C1874	CPT				Both			7945	3575.25	3575.25	7150.5		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	5879.3							Fee Schedule																													7150.5							Fee Schedule																																															
WALLFLEX BILIARY STENT METAL #M00570530	278	RC	C1874	CPT				Both			8925	4016.25	4016.25	8032.5		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	6604.5							Fee Schedule																													8032.5							Fee Schedule																																															
WALLFLEX BILIARY STENT METAL #M00570620	278	RC	C1874	CPT				Both			5286	2378.7	2378.7	4757.4		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	3911.64							Fee Schedule																													4757.4							Fee Schedule																																															
WALLFLEX BILIARY STENT METAL #M00570630	278	RC	C1874	CPT				Both			5286	2378.7	2378.7	4757.4		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	3911.64							Fee Schedule																													4757.4							Fee Schedule																																															
WALLFLEX BILIARY STENT METAL #M00570650	278	RC	C1874	CPT				Both			5286	2378.7	2378.7	4757.4		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	3911.64							Fee Schedule																													4757.4							Fee Schedule																																															
WALLFLEX BILIARY STENT METAL #M00570660	278	RC	C1874	CPT				Both			5286	2378.7	2378.7	4757.4		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	3911.64							Fee Schedule																													4757.4							Fee Schedule																																															
WALLFLEX COLON STENT #M00565060	278	RC	C2625	CPT				Both			8136.45	3661.4	3661.4	7322.81		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	6020.97							Fee Schedule																													7322.81							Fee Schedule																																															
WALLFLEX COLON STENT #M00565130	278	RC	C2625	CPT				Both			7933	3569.85	3569.85	7139.7		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	5870.42							Fee Schedule																													7139.7							Fee Schedule																																															
WALLFLEX ESOPHAGEAL STENT #M00516740	278	RC	C1874	CPT				Both			7517	3382.65	3382.65	6765.3		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	5562.58							Fee Schedule																													6765.3							Fee Schedule																																															
WALLFLEX ESOPHOGEAL STENT #M00516930	278	RC	C1874	CPT				Both			7425	3341.25	3341.25	6682.5		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	5494.5							Fee Schedule																													6682.5							Fee Schedule																																															
WALLSTENT BILIARY STENT H965431200	278	RC	C1874	CPT				Both			4851	2182.95	2182.95	4365.9		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	3589.74							Fee Schedule																													4365.9							Fee Schedule																																															
WARFARIN (JANTOVEN) 1 MG TABLET	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
WARFARIN (JANTOVEN) 2 MG TABLET	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
WARFARIN (JANTOVEN) 2.5 MG TABLET	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
WARFARIN (JANTOVEN) 3 MG TABLET	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
WARFARIN (JANTOVEN) 4 MG TABLET	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
WARFARIN (JANTOVEN) 5 MG TABLET	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
WARFARIN (JANTOVEN) 7.5 MG TABLET	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
WARFARIN 936 2ML PLASMA	301	RC	80299	CPT				Both			100.8	45.36	13.42	90.72	13.42							Fee Schedule		18.64							Fee Schedule		19.2							Fee Schedule		18.64							Fee Schedule											90.72							Fee Schedule																				18.64							Fee Schedule																				
WASH BASIN GREY 71/2QT.	270	RC						Both			2.1	0.95	0.95	1.89	1.37							Fee Schedule		1.55							Fee Schedule																													1.89							Fee Schedule																																															
WATER BOTTLE #77-7900	270	RC						Both			19.16	8.62	8.62	17.24	12.45							Fee Schedule		14.18							Fee Schedule																													17.24							Fee Schedule																																															
WATERBUG FLOOR SUCTION 90010 (COLBY)	270	RC						Both			78.75	35.44	17.34	70.88	51.19							Fee Schedule		58.28							Fee Schedule																				18.64							Fee Schedule		70.88							Fee Schedule		21.44							Fee Schedule		17.34							Fee Schedule											21.44							Fee Schedule		17.34							Fee Schedule		
WAVE GUIDE	272	RC						Both			405.3	182.39	182.39	364.77	263.45							Fee Schedule		299.92							Fee Schedule																													364.77							Fee Schedule																																															
WAYNE PNEUMOTHORAX CATH SET 14FR G56537	272	RC						Both			853	383.85	383.85	767.7	554.45							Fee Schedule		631.22							Fee Schedule																													767.7							Fee Schedule																																															
WBC	305	RC	85048	CPT				Both			38.85	17.48	2.25	34.97	2.25							Fee Schedule		2.82							Fee Schedule		2.62							Fee Schedule		2.54							Fee Schedule											34.97							Fee Schedule																				2.54							Fee Schedule																				
WEBRIL 2 INCH 1418 UNSTERILE	271	RC						Both			3	1.35	1.35	2.7	1.95							Fee Schedule		2.22							Fee Schedule																													2.7							Fee Schedule																																															
WEBRIL 3 INCH 2059 UNSTERILE	271	RC						Both			4.2	1.89	1.89	3.78	2.73							Fee Schedule		3.11							Fee Schedule																													3.78							Fee Schedule																																															
WEBRIL 4  #2502	271	RC						Both			3	1.35	1.35	2.92	1.95							Fee Schedule		2.22							Fee Schedule																				2.54							Fee Schedule		2.7							Fee Schedule		2.92							Fee Schedule		2.36							Fee Schedule											2.92							Fee Schedule		2.36							Fee Schedule		
WEBRIL 6  #2554	271	RC						Both			6	2.7	2.7	5.4	3.9							Fee Schedule		4.44							Fee Schedule																													5.4							Fee Schedule																																															
WECK LIGATION CLIP #544230 ( SENECA)	272	RC						Both			101.85	45.83	45.83	91.67	66.2							Fee Schedule		75.37							Fee Schedule																													91.67							Fee Schedule																																															
WEIL FELIX PANEL 37507 SERUM	302	RC	86609	CPT				Both			86.1	38.75	11.45	77.49	11.45							Fee Schedule		14.31							Fee Schedule		13.27							Fee Schedule		12.88							Fee Schedule											77.49							Fee Schedule																				12.88							Fee Schedule																				
WELCH ALLYN PROBE TUBES #39421	270	RC						Both			3	1.35	1.35	2.7	1.95							Fee Schedule		2.22							Fee Schedule																													2.7							Fee Schedule																																															
WELCHOL 625 MG (COLESEVELAM HCL) TABLET	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
WEST NILE VIRUS (16012) 2ML SERUM IGM	302	RC	86790	CPT				Both			150.15	67.57	11.45	135.14	11.45							Fee Schedule		14.31							Fee Schedule		13.27							Fee Schedule		12.88							Fee Schedule		12.88							Fee Schedule		135.14							Fee Schedule		14.81							Fee Schedule		11.98							Fee Schedule		12.88							Fee Schedule		14.81							Fee Schedule		11.98							Fee Schedule		
WEST NILE VIRUS CSF 36597  IGG/IGM  2ML	302	RC	86790	CPT				Both			150.15	67.57	11.45	135.14	11.45							Fee Schedule		14.31							Fee Schedule		13.27							Fee Schedule		12.88							Fee Schedule											135.14							Fee Schedule																				12.88							Fee Schedule																				
WET PREP	306	RC	87210	CPT				Both			29.4	13.23	4.19	26.46	4.19							Fee Schedule		5.82							Fee Schedule		5.99							Fee Schedule		5.82							Fee Schedule											26.46							Fee Schedule																				5.82							Fee Schedule																				
WHISPER SWIVEL ( SENECA )	271	RC						Both			78.75	35.44	11.98	70.88	51.19							Fee Schedule		58.28							Fee Schedule																				12.88							Fee Schedule		70.88							Fee Schedule		14.81							Fee Schedule		11.98							Fee Schedule											14.81							Fee Schedule		11.98							Fee Schedule		
WHITE FOAM DRESSING 3.75 X3.75  #46-906	272	RC	A6212	CPT				Both			8.4	3.78	3.78	14.81	8.74							Fee Schedule		6.22							Fee Schedule		14.26							Fee Schedule		10.93							Fee Schedule		12.88							Fee Schedule		7.56							Fee Schedule		14.81							Fee Schedule		11.98							Fee Schedule											14.81							Fee Schedule		11.98							Fee Schedule		
WHITE FOAM POLYDERM DSG. 6X6 DEROYAL	272	RC	A6210	CPT				Both			15.75	7.09	5.41	29.25	17.94							Fee Schedule		11.66							Fee Schedule		29.25							Fee Schedule		22.42							Fee Schedule		5.82							Fee Schedule		14.18							Fee Schedule		6.69							Fee Schedule		5.41							Fee Schedule											6.69							Fee Schedule		5.41							Fee Schedule		
WHITE PETROLATUM  5 GM FOILPACS	250	RC	A9270	CPT				Both			0.11	0.05	0.01	0.1	0.01							Fee Schedule		0.08							Fee Schedule																													0.1							Fee Schedule																																															
WHITE PETROLATUM 71 gm	250	RC	A9270	CPT				Both			4.1	1.85	0.01	15.92	0.01							Fee Schedule		3.03							Fee Schedule																				13.84							Fee Schedule		3.69							Fee Schedule		15.92							Fee Schedule		12.87							Fee Schedule											15.92							Fee Schedule		12.87							Fee Schedule		
WHOLE BODY SUIT    (SLOAN MEDICAL)	271	RC						Both			2.1	0.95	0.95	32.66	1.37							Fee Schedule		1.55							Fee Schedule																				28.4							Fee Schedule		1.89							Fee Schedule		32.66							Fee Schedule		26.41							Fee Schedule											32.66							Fee Schedule		26.41							Fee Schedule		
WINRHO SDF 1000 MCG (5000 UNITS) VIAL	636	RC	J2792	CPT				Both			2563.05	1153.37	28.71	2306.75		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	34.26							Fee Schedule		34.93							Fee Schedule		28.71							Fee Schedule											2306.75							Fee Schedule																																															
WINRHO SDF 300 MCG (1500 UNITS) VIAL	636	RC	J2792	CPT				Both			719.25	323.66	28.71	647.33		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	34.26							Fee Schedule		34.93							Fee Schedule		28.71							Fee Schedule											647.33							Fee Schedule																																															
WOLFE HULKA CLIPS	278	RC	C1760	CPT				Both			66.15	29.77	29.77	59.54		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	48.95							Fee Schedule																													59.54							Fee Schedule																																															
WORD BARTH. CATHETER 10FR. 5CC  564000	278	RC	C1729	CPT				Both			61	27.45	27.45	54.9		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	45.14							Fee Schedule																				33.91							Fee Schedule		54.9							Fee Schedule		39							Fee Schedule		31.54							Fee Schedule											39							Fee Schedule		31.54							Fee Schedule		
WOUND CLEANSER #MSC6008EP	272	RC	A6260	CPT				Both			11	4.95	0.52	39	0.52							Fee Schedule		8.14							Fee Schedule																				33.91							Fee Schedule		9.9							Fee Schedule		39							Fee Schedule		31.54							Fee Schedule											39							Fee Schedule		31.54							Fee Schedule		
WOUND CULTURE SWAB 14-907-20	272	RC						Both			2	0.9	0.9	1.8	1.3							Fee Schedule		1.48							Fee Schedule																													1.8							Fee Schedule																																															
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOS					989	DRG		Inpatient			15783.35	7102.51	7102.51	7102.51							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period. 							0		No services performed during 15 month lookback period							0		No services provided during 15 month lookback period				6355.19	6355.19	6355.19	1 through 10									0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback							0		No services provided during 15 month lookback period							0		No services provided during 15 month lookback period	
WOUND MEASURING RULER 6  #MSCEDURULER	270	RC						Both			1	0.45	0.45	0.9	0.65							Fee Schedule		0.74							Fee Schedule																													0.9							Fee Schedule																																															
WOUND THERAPY SYSTEM 7-DAY VIAKIT077D01	272	RC	A6550	CPT				Both			2280.6	1026.27	19.58	2052.54	19.58							Fee Schedule		1687.64							Fee Schedule		32.29							Fee Schedule		23.89							Fee Schedule											2052.54							Fee Schedule																																															
WOUND VAC AB THERAPY DRESSING #M8275026	272	RC	A6550	CPT				Both			1160.25	522.11	19.58	1044.23	19.58							Fee Schedule		858.59							Fee Schedule		32.29							Fee Schedule		23.89							Fee Schedule											1044.23							Fee Schedule																																															
WOUND VAC CANISTER #NP-1006	272	RC	A7000	CPT				Both			62	27.9	6.56	55.8	6.56							Fee Schedule		45.88							Fee Schedule		10.82							Fee Schedule																				55.8							Fee Schedule																																															
WOUND VAC DRESSING LG BLACK #NP-0502	272	RC	A6550	CPT				Both			85	38.25	19.58	76.5	19.58							Fee Schedule		62.9							Fee Schedule		32.29							Fee Schedule		23.89							Fee Schedule		31.35							Fee Schedule		76.5							Fee Schedule		36.05							Fee Schedule		29.16							Fee Schedule											36.05							Fee Schedule		29.16							Fee Schedule		
WOUND VAC DRESSING MED BLACK #NP-6002P	272	RC	A6550	CPT				Both			87	39.15	19.58	78.3	19.58							Fee Schedule		64.38							Fee Schedule		32.29							Fee Schedule		23.89							Fee Schedule		31.35							Fee Schedule		78.3							Fee Schedule		36.05							Fee Schedule		29.16							Fee Schedule											36.05							Fee Schedule		29.16							Fee Schedule		
WOUND VAC DRESSING SM BLACK #NP-6001P	272	RC	A6550	CPT				Both			78	35.1	9.77	70.2	19.58							Fee Schedule		57.72							Fee Schedule		32.29							Fee Schedule		23.89							Fee Schedule		10.5							Fee Schedule		70.2							Fee Schedule		12.08							Fee Schedule		9.77							Fee Schedule											12.08							Fee Schedule		9.77							Fee Schedule		
WOUND VAC FOAM SILVER LARGE  ( KCI )	272	RC	A6550	CPT				Both			224.7	101.12	19.58	202.23	19.58							Fee Schedule		166.28							Fee Schedule		32.29							Fee Schedule		23.89							Fee Schedule		31.35							Fee Schedule		202.23							Fee Schedule		36.05							Fee Schedule		29.16							Fee Schedule											36.05							Fee Schedule		29.16							Fee Schedule		
WOUND VAC PUMP USE CHARGE  ( KCI )	270	RC	E2402	CPT				Both			253.05	113.87	29.16	4821.04	4821.04							Fee Schedule		187.26							Fee Schedule		908.4							Fee Schedule											31.35							Fee Schedule		227.75							Fee Schedule		36.05							Fee Schedule		29.16							Fee Schedule											36.05							Fee Schedule		29.16							Fee Schedule		
WOUND VAC PUMP USE CHARGE DEROYAL	271	RC	E2402	CPT				Both			63	28.35	28.35	4821.04	4821.04							Fee Schedule		46.62							Fee Schedule		908.4							Fee Schedule											31.35							Fee Schedule		56.7							Fee Schedule		36.05							Fee Schedule		29.16							Fee Schedule											36.05							Fee Schedule		29.16							Fee Schedule		
WOUND VAC TRAC PAD M8275057-10	272	RC						Both			63	28.35	28.35	56.7	40.95							Fee Schedule		46.62							Fee Schedule																				31.35							Fee Schedule		56.7							Fee Schedule		36.05							Fee Schedule		29.16							Fee Schedule											36.05							Fee Schedule		29.16							Fee Schedule		
WOUND VAC TRANSEAL DRESSING 46-326B	272	RC	A6550	CPT				Both			6.3	2.84	2.84	1014.23	19.58							Fee Schedule		4.66							Fee Schedule		32.29							Fee Schedule		23.89							Fee Schedule		881.94							Fee Schedule		5.67							Fee Schedule		1014.23							Fee Schedule		820.2							Fee Schedule											1014.23							Fee Schedule		820.2							Fee Schedule		
WOUND VAC TUBING & PAD M8275057	272	RC	A6550	CPT				Both			61.95	27.88	19.58	1014.23	19.58							Fee Schedule		45.84							Fee Schedule		32.29							Fee Schedule		23.89							Fee Schedule		881.94							Fee Schedule		55.76							Fee Schedule		1014.23							Fee Schedule		820.2							Fee Schedule											1014.23							Fee Schedule		820.2							Fee Schedule		
WOUND VAC TUBING CAP M8275069	272	RC	A6550	CPT				Both			6.3	2.84	2.84	32.29	19.58							Fee Schedule		4.66							Fee Schedule		32.29							Fee Schedule		23.89							Fee Schedule											5.67							Fee Schedule																																															
WOUND VAC VERSA FOAM # M6275034	272	RC	A6550	CPT				Both			51.45	23.15	19.58	46.31	19.58							Fee Schedule		38.07							Fee Schedule		32.29							Fee Schedule		23.89							Fee Schedule		31.35							Fee Schedule		46.31							Fee Schedule		36.05							Fee Schedule		29.16							Fee Schedule											36.05							Fee Schedule		29.16							Fee Schedule		
WOUND VAC VERS-FOAM SMALL DRESSING M6275	272	RC	A6550	CPT				Both			34.65	15.59	15.59	36.05	19.58							Fee Schedule		25.64							Fee Schedule		32.29							Fee Schedule		23.89							Fee Schedule		31.35							Fee Schedule		31.19							Fee Schedule		36.05							Fee Schedule		29.16							Fee Schedule											36.05							Fee Schedule		29.16							Fee Schedule		
WOUND VAC WHITE FOAM KIT MED #NP-0103	272	RC	A6550	CPT				Both			108	48.6	19.58	97.2	19.58							Fee Schedule		79.92							Fee Schedule		32.29							Fee Schedule		23.89							Fee Schedule		31.35							Fee Schedule		97.2							Fee Schedule		36.05							Fee Schedule		29.16							Fee Schedule											36.05							Fee Schedule		29.16							Fee Schedule		
WOUND VAC. CANNISTER SET NP-1004-10	272	RC	A7000	CPT				Both			71.4	32.13	6.56	64.26	6.56							Fee Schedule		52.84							Fee Schedule		10.82							Fee Schedule											31.35							Fee Schedule		64.26							Fee Schedule		36.05							Fee Schedule		29.16							Fee Schedule											36.05							Fee Schedule		29.16							Fee Schedule		
WOUND VAC. Y- CONNECTOR #NP-120-10	272	RC	A6550	CPT				Both			14	6.3	6.3	36.05	19.58							Fee Schedule		10.36							Fee Schedule		32.29							Fee Schedule		23.89							Fee Schedule		31.35							Fee Schedule		12.6							Fee Schedule		36.05							Fee Schedule		29.16							Fee Schedule											36.05							Fee Schedule		29.16							Fee Schedule		
WOUND VAD DRAP M6275067/5	272	RC	A6550	CPT				Both			192.15	86.47	19.58	172.94	19.58							Fee Schedule		142.19							Fee Schedule		32.29							Fee Schedule		23.89							Fee Schedule		31.35							Fee Schedule		172.94							Fee Schedule		36.05							Fee Schedule		29.16							Fee Schedule											36.05							Fee Schedule		29.16							Fee Schedule		
WRIGHT MEDICAL 2.7 SCREW 14 (4900-0314)	278	RC	C1713	CPT				Both			92.4	41.58	9.77	83.16		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	68.38							Fee Schedule																				10.5							Fee Schedule		83.16							Fee Schedule		12.08							Fee Schedule		9.77							Fee Schedule											12.08							Fee Schedule		9.77							Fee Schedule		
WRIGHT MEDICAL 2.7 SCREW 16 (4900-0316)	278	RC	C1713	CPT				Both			92.4	41.58	29.16	83.16		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	68.38							Fee Schedule																				31.35							Fee Schedule		83.16							Fee Schedule		36.05							Fee Schedule		29.16							Fee Schedule											36.05							Fee Schedule		29.16							Fee Schedule		
WRIGHT MEDICAL 3.5 SCREW 12 (4900-0712)	278	RC	C1713	CPT				Both			92.4	41.58	29.16	83.16		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	68.38							Fee Schedule																				31.35							Fee Schedule		83.16							Fee Schedule		36.05							Fee Schedule		29.16							Fee Schedule											36.05							Fee Schedule		29.16							Fee Schedule		
WRIGHT MEDICAL 3.5 SCREW 14 (4900-0714)	278	RC	C1713	CPT				Both			92.4	41.58	41.58	83.16		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	68.38							Fee Schedule																													83.16							Fee Schedule																																															
WRIST BRACE LEFT LARGE	274	RC	L3984	CPT				Both			157.5	70.88	70.88	472.19		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	116.55							Fee Schedule		472.19							Fee Schedule		329.1							Fee Schedule											141.75							Fee Schedule																																															
WRIST BRACE LEFT MEDIUM	274	RC	L3984	CPT				Both			151.2	68.04	68.04	472.19		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	111.89							Fee Schedule		472.19							Fee Schedule		329.1							Fee Schedule											136.08							Fee Schedule																																															
WRIST BRACE LEFT SMALL	274	RC	L3984	CPT				Both			148.05	66.62	66.62	472.19		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	109.56							Fee Schedule		472.19							Fee Schedule		329.1							Fee Schedule											133.25							Fee Schedule																																															
WRIST BRACE RIGHT LARGE	274	RC	L3984	CPT				Both			157.5	70.88	70.88	527.21		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	116.55							Fee Schedule		472.19							Fee Schedule		329.1							Fee Schedule		458.44							Fee Schedule		141.75							Fee Schedule		527.21							Fee Schedule		426.35							Fee Schedule											527.21							Fee Schedule		426.35							Fee Schedule		
WRIST BRACE RIGHT MEDIUM	274	RC	L3984	CPT				Both			151.2	68.04	68.04	527.21		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	111.89							Fee Schedule		472.19							Fee Schedule		329.1							Fee Schedule		458.44							Fee Schedule		136.08							Fee Schedule		527.21							Fee Schedule		426.35							Fee Schedule											527.21							Fee Schedule		426.35							Fee Schedule		
WRIST BRACE RIGHT SMALL	274	RC	L3984	CPT				Both			148.05	66.62	66.62	527.21		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	109.56							Fee Schedule		472.19							Fee Schedule		329.1							Fee Schedule		458.44							Fee Schedule		133.25							Fee Schedule		527.21							Fee Schedule		426.35							Fee Schedule											527.21							Fee Schedule		426.35							Fee Schedule		
WRIST ELASTIC LG L   CLINIC	270	RC						Both			129.15	58.12	58.12	527.21	83.95							Fee Schedule		95.57							Fee Schedule																				458.44							Fee Schedule		116.24							Fee Schedule		527.21							Fee Schedule		426.35							Fee Schedule											527.21							Fee Schedule		426.35							Fee Schedule		
WRIST ELASTIC LG R   CLINIC	270	RC						Both			129.15	58.12	58.12	527.21	83.95							Fee Schedule		95.57							Fee Schedule																				458.44							Fee Schedule		116.24							Fee Schedule		527.21							Fee Schedule		426.35							Fee Schedule											527.21							Fee Schedule		426.35							Fee Schedule		
WRIST ELASTIC MED L   CLINIC	270	RC						Both			129.15	58.12	58.12	527.21	83.95							Fee Schedule		95.57							Fee Schedule																				458.44							Fee Schedule		116.24							Fee Schedule		527.21							Fee Schedule		426.35							Fee Schedule											527.21							Fee Schedule		426.35							Fee Schedule		
WRIST ELASTIC MED R    CLINIC	270	RC						Both			129.15	58.12	58.12	116.24	83.95							Fee Schedule		95.57							Fee Schedule																													116.24							Fee Schedule																																															
WRIST ELASTIC SM L   CLINIC	270	RC						Both			129.15	58.12	58.12	116.24	83.95							Fee Schedule		95.57							Fee Schedule																													116.24							Fee Schedule																																															
WRIST ELASTIC SM R   CLINIC	274	RC	L3808	CPT				Both			129.15	58.12	58.12	386.86		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	95.57							Fee Schedule		386.86							Fee Schedule																				116.24							Fee Schedule																																															
WRIST LT	320	RC	73110	CPT				Both			315	141.75	15.33	318	21.42							Fee Schedule		25.19							Fee Schedule											15.33							Fee Schedule											283.5							Fee Schedule																				318							Per Diem																				
WRIST RT	320	RC	73110	CPT				Both			315	141.75	15.33	318	21.42							Fee Schedule		25.19							Fee Schedule											15.33							Fee Schedule											283.5							Fee Schedule																				318							Per Diem																				
WRIST SPLINT ALUM. LEFT LARGE #79-72207	274	RC	L3984	CPT				Both			14	6.3	6.3	472.19		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	10.36							Fee Schedule		472.19							Fee Schedule		329.1							Fee Schedule		375.59							Fee Schedule		12.6							Fee Schedule		431.93							Fee Schedule		349.3							Fee Schedule											431.93							Fee Schedule		349.3							Fee Schedule		
WRIST SPLINT ALUM. LEFT MEDIUM #79-72205	274	RC	L3984	CPT				Both			14	6.3	6.3	472.19		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	10.36							Fee Schedule		472.19							Fee Schedule		329.1							Fee Schedule											12.6							Fee Schedule																																															
WRIST SPLINT ALUM. LEFT SMALL #79-72203	274	RC	L3984	CPT				Both			14	6.3	6.3	472.19		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	10.36							Fee Schedule		472.19							Fee Schedule		329.1							Fee Schedule											12.6							Fee Schedule																																															
WRIST SPLINT ALUM. RIGHT LARGE #79-72217	274	RC	L3984	CPT				Both			14	6.3	6.3	527.21		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	10.36							Fee Schedule		472.19							Fee Schedule		329.1							Fee Schedule		458.44							Fee Schedule		12.6							Fee Schedule		527.21							Fee Schedule		426.35							Fee Schedule											527.21							Fee Schedule		426.35							Fee Schedule		
WRIST SPLINT ALUM. RIGHT MEDIUM 79-72215	274	RC	L3984	CPT				Both			14	6.3	6.3	527.21		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	10.36							Fee Schedule		472.19							Fee Schedule		329.1							Fee Schedule		458.44							Fee Schedule		12.6							Fee Schedule		527.21							Fee Schedule		426.35							Fee Schedule											527.21							Fee Schedule		426.35							Fee Schedule		
WRIST SPLINT ALUM. RIGHT SMALL #79-72213	274	RC	L3984	CPT				Both			14	6.3	6.3	527.21		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	10.36							Fee Schedule		472.19							Fee Schedule		329.1							Fee Schedule		458.44							Fee Schedule		12.6							Fee Schedule		527.21							Fee Schedule		426.35							Fee Schedule											527.21							Fee Schedule		426.35							Fee Schedule		
WRIST SPLINT LEATHER LEFT LG #79-87017	274	RC	L3984	CPT				Both			18	8.1	8.1	527.21		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	13.32							Fee Schedule		472.19							Fee Schedule		329.1							Fee Schedule		458.44							Fee Schedule		16.2							Fee Schedule		527.21							Fee Schedule		426.35							Fee Schedule											527.21							Fee Schedule		426.35							Fee Schedule		
WRIST SPLINT LEATHER LEFT MED #79-87015	274	RC	L3984	CPT				Both			18	8.1	8.1	527.21		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	13.32							Fee Schedule		472.19							Fee Schedule		329.1							Fee Schedule		458.44							Fee Schedule		16.2							Fee Schedule		527.21							Fee Schedule		426.35							Fee Schedule											527.21							Fee Schedule		426.35							Fee Schedule		
WRIST SPLINT LEATHER LEFT SM #79-87013	274	RC	L3984	CPT				Both			18	8.1	8.1	527.21		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	13.32							Fee Schedule		472.19							Fee Schedule		329.1							Fee Schedule		458.44							Fee Schedule		16.2							Fee Schedule		527.21							Fee Schedule		426.35							Fee Schedule											527.21							Fee Schedule		426.35							Fee Schedule		
WRIST SPLINT LEATHER LEFT XL #79-87018	274	RC	L3984	CPT				Both			18	8.1	8.1	527.21		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	13.32							Fee Schedule		472.19							Fee Schedule		329.1							Fee Schedule		458.44							Fee Schedule		16.2							Fee Schedule		527.21							Fee Schedule		426.35							Fee Schedule											527.21							Fee Schedule		426.35							Fee Schedule		
WRIST SPLINT LEATHER LEFT XS #79-87012	274	RC	L3908	CPT				Both			17.85	8.03	8.03	527.21		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	13.21							Fee Schedule		69.39							Fee Schedule		52.5							Fee Schedule		458.44							Fee Schedule		16.07							Fee Schedule		527.21							Fee Schedule		426.35							Fee Schedule											527.21							Fee Schedule		426.35							Fee Schedule		
WRIST SPLINT LEATHER RIGHT LG #79-87007	274	RC	L3984	CPT				Both			18	8.1	8.1	527.21		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	13.32							Fee Schedule		472.19							Fee Schedule		329.1							Fee Schedule		458.44							Fee Schedule		16.2							Fee Schedule		527.21							Fee Schedule		426.35							Fee Schedule											527.21							Fee Schedule		426.35							Fee Schedule		
WRIST SPLINT LEATHER RIGHT MED #79-87005	274	RC	L3984	CPT				Both			18	8.1	8.1	527.21		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	13.32							Fee Schedule		472.19							Fee Schedule		329.1							Fee Schedule		458.44							Fee Schedule		16.2							Fee Schedule		527.21							Fee Schedule		426.35							Fee Schedule											527.21							Fee Schedule		426.35							Fee Schedule		
WRIST SPLINT LEATHER RIGHT SM #79-87003	274	RC	L3984	CPT				Both			18	8.1	8.1	472.19		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	13.32							Fee Schedule		472.19							Fee Schedule		329.1							Fee Schedule		67.37							Fee Schedule		16.2							Fee Schedule		77.48							Fee Schedule		62.65							Fee Schedule											77.48							Fee Schedule		62.65							Fee Schedule		
WRIST SPLINT LEATHER RIGHT XL #79-87008	274	RC	L3984	CPT				Both			18	8.1	8.1	527.21		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	13.32							Fee Schedule		472.19							Fee Schedule		329.1							Fee Schedule		458.44							Fee Schedule		16.2							Fee Schedule		527.21							Fee Schedule		426.35							Fee Schedule											527.21							Fee Schedule		426.35							Fee Schedule		
WRIST SPLINT LEATHER RIGHT XS #79-87002	274	RC	L3908	CPT				Both			17.85	8.03	8.03	527.21		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	13.21							Fee Schedule		69.39							Fee Schedule		52.5							Fee Schedule		458.44							Fee Schedule		16.07							Fee Schedule		527.21							Fee Schedule		426.35							Fee Schedule											527.21							Fee Schedule		426.35							Fee Schedule		
WRISTLET NEOG. CORP.TUN. LEFT LG.	274	RC	L3908	CPT				Both			86.1	38.75	38.75	527.21		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	63.71							Fee Schedule		69.39							Fee Schedule		52.5							Fee Schedule		458.44							Fee Schedule		77.49							Fee Schedule		527.21							Fee Schedule		426.35							Fee Schedule											527.21							Fee Schedule		426.35							Fee Schedule		
WRISTLET NEOP.CARP.TUN.LARGE RIGHT(ZIMME	274	RC	L3908	CPT				Both			86.1	38.75	38.75	527.21		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	63.71							Fee Schedule		69.39							Fee Schedule		52.5							Fee Schedule		458.44							Fee Schedule		77.49							Fee Schedule		527.21							Fee Schedule		426.35							Fee Schedule											527.21							Fee Schedule		426.35							Fee Schedule		
WRISTLET NEOP.CARP.TUN.MED.  RIGHT(ZIMME	274	RC	L3908	CPT				Both			86.1	38.75	38.75	77.49		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	63.71							Fee Schedule		69.39							Fee Schedule		52.5							Fee Schedule		67.37							Fee Schedule		77.49							Fee Schedule		77.48							Fee Schedule		62.65							Fee Schedule											77.48							Fee Schedule		62.65							Fee Schedule		
WRISTLET NEOP.CARP.TUN.MEDIU.LEFT(ZIMMER	274	RC	L3908	CPT				Both			86.1	38.75	38.75	77.49		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	63.71							Fee Schedule		69.39							Fee Schedule		52.5							Fee Schedule		67.37							Fee Schedule		77.49							Fee Schedule		77.48							Fee Schedule		62.65							Fee Schedule											77.48							Fee Schedule		62.65							Fee Schedule		
WRISTLET NEOP.CARP.TUN.SMALL LEFT(ZIMMER	274	RC	L3908	CPT				Both			52.5	23.63	23.63	77.48		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	38.85							Fee Schedule		69.39							Fee Schedule		52.5							Fee Schedule		67.37							Fee Schedule		47.25							Fee Schedule		77.48							Fee Schedule		62.65							Fee Schedule											77.48							Fee Schedule		62.65							Fee Schedule		
WRISTLET NEOP.CARP.TUN.SMALL RIGHT(ZIMME	274	RC	L3908	CPT				Both			52.5	23.63	23.63	77.48		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	38.85							Fee Schedule		69.39							Fee Schedule		52.5							Fee Schedule		67.37							Fee Schedule		47.25							Fee Schedule		77.48							Fee Schedule		62.65							Fee Schedule											77.48							Fee Schedule		62.65							Fee Schedule		
WRISTLET NEOP.CARP.TUN.XLG.  RIGHT(ZIMME	274	RC	L3908	CPT				Both			86.1	38.75	38.75	77.49		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	63.71							Fee Schedule		69.39							Fee Schedule		52.5							Fee Schedule		67.37							Fee Schedule		77.49							Fee Schedule		77.48							Fee Schedule		62.65							Fee Schedule											77.48							Fee Schedule		62.65							Fee Schedule		
WRISTLET NEOP.CARP.TUN.XLGE LEFT(ZIMMER	274	RC	L3908	CPT				Both			86.1	38.75	38.75	77.49		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	63.71							Fee Schedule		69.39							Fee Schedule		52.5							Fee Schedule		67.37							Fee Schedule		77.49							Fee Schedule		77.48							Fee Schedule		62.65							Fee Schedule											77.48							Fee Schedule		62.65							Fee Schedule		
XARELTO  2.5MG TABLET	250	RC	A9270	CPT				Both			31	13.95	0.01	77.48	0.01							Fee Schedule		22.94							Fee Schedule																				67.37							Fee Schedule		27.9							Fee Schedule		77.48							Fee Schedule		62.65							Fee Schedule											77.48							Fee Schedule		62.65							Fee Schedule		
XARELTO 10 MG TABLET	250	RC	A9270	CPT				Both			31.5	14.18	0.01	77.48	0.01							Fee Schedule		23.31							Fee Schedule																				67.37							Fee Schedule		28.35							Fee Schedule		77.48							Fee Schedule		62.65							Fee Schedule											77.48							Fee Schedule		62.65							Fee Schedule		
XARELTO 15MG TABLET	250	RC	A9270	CPT				Both			31.5	14.18	0.01	77.48	0.01							Fee Schedule		23.31							Fee Schedule																				67.37							Fee Schedule		28.35							Fee Schedule		77.48							Fee Schedule		62.65							Fee Schedule											77.48							Fee Schedule		62.65							Fee Schedule		
XARELTO 2.5MG TABLET	250	RC	A9270	CPT				Both			31	13.95	0.01	27.9	0.01							Fee Schedule		22.94							Fee Schedule																													27.9							Fee Schedule																																															
XARELTO 20 MG TABLET	250	RC	A9270	CPT				Both			31.5	14.18	0.01	28.35	0.01							Fee Schedule		23.31							Fee Schedule																													28.35							Fee Schedule																																															
XENOSURE BIOLOGIC VASC. PATCH # 0.8P8	278	RC	C1768	CPT				Both			792	356.4	356.4	712.8		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	586.08							Fee Schedule																													712.8							Fee Schedule																																															
XEROFORM 1X8 (MEDLINE) CUR253180	272	RC	A6223	CPT				Both			1	0.45	0.45	3.56	2.18							Fee Schedule		0.74							Fee Schedule		3.56							Fee Schedule		2.73							Fee Schedule											0.9							Fee Schedule																																															
XEROFORM 4X4 (MEDLINE) NON253440	272	RC	A6223	CPT				Both			2	0.9	0.9	3.56	2.18							Fee Schedule		1.48							Fee Schedule		3.56							Fee Schedule		2.73							Fee Schedule											1.8							Fee Schedule																																															
XEROFORM 5X9 #8884433605	272	RC						Both			2	0.9	0.9	1.8	1.3							Fee Schedule		1.48							Fee Schedule																													1.8							Fee Schedule																																															
XEROFORM DSG 5X9 EA	272	RC						Both			3.41	1.53	1.53	3.98	2.22							Fee Schedule		2.52							Fee Schedule																				3.46							Fee Schedule		3.07							Fee Schedule		3.98							Fee Schedule		3.22							Fee Schedule											3.98							Fee Schedule		3.22							Fee Schedule		
XIAFLEX INJ POWDER FOR SOLUTION 0.9MG	636	RC	J0775	CPT				Both			24628.35	11082.76	3.22	22165.52		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	78.36							Fee Schedule		78.02							Fee Schedule											3.46							Fee Schedule		22165.52							Fee Schedule		3.98							Fee Schedule		3.22							Fee Schedule											3.98							Fee Schedule		3.22							Fee Schedule		
XIFAXAN 200 MG (RIFAXIMIN) TABLET	250	RC	A9270	CPT				Both			12.6	5.67	0.01	11.34	0.01							Fee Schedule		9.32							Fee Schedule																													11.34							Fee Schedule																																															
XIFAXAN 550 MG (RIFAXIMIN) TABLET	250	RC	A9270	CPT				Both			81.9	36.86	0.01	73.71	0.01							Fee Schedule		60.61							Fee Schedule																													73.71							Fee Schedule																																															
X-MAS TREE ADAPTER  TRI-ANIM	271	RC						Both			9.45	4.25	4.25	87.11	6.14							Fee Schedule		6.99							Fee Schedule																				75.75							Fee Schedule		8.51							Fee Schedule		87.11							Fee Schedule		70.44							Fee Schedule											87.11							Fee Schedule		70.44							Fee Schedule		
XOLAIR (OMALIZUMAB)150 MG VIAL INJECTION	636	RC	J2357	CPT				Both			1859.55	836.8	41.83	1673.6		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	41.83							Fee Schedule		46.86							Fee Schedule																				1673.6							Fee Schedule																																															
XOMED NASAL SEPTAL BUTTON #15-24105	272	RC						Both			322.35	145.06	145.06	290.12	209.53							Fee Schedule		238.54							Fee Schedule																													290.12							Fee Schedule																																															
XOMED NERVE LOCATOR    8562010	272	RC						Both			132.3	59.54	59.54	119.07	86							Fee Schedule		97.9							Fee Schedule																													119.07							Fee Schedule																																															
XOPENEX 0.31 MG/3 ML INH AEROSOL RT	250	RC	J7614	CPT				Both			11.55	5.2	0.06	52.32	0.06							Fee Schedule		8.55							Fee Schedule		0.08							Fee Schedule											45.5							Fee Schedule		10.4							Fee Schedule		52.32							Fee Schedule		42.31							Fee Schedule											52.32							Fee Schedule		42.31							Fee Schedule		
XOPENEX 0.63 MG/3 ML INH AEROSOL (RT)	250	RC	J7614	CPT				Both			23.48	10.57	0.06	21.13	0.06							Fee Schedule		17.38							Fee Schedule		0.08							Fee Schedule																				21.13							Fee Schedule																																															
XOPENEX 1.25 MG/3 ML INH AEROSOL (RT)	250	RC	J7614	CPT				Both			21	9.45	0.06	18.9	0.06							Fee Schedule		15.54							Fee Schedule		0.08							Fee Schedule																				18.9							Fee Schedule																																															
XOPENEX HFA MDI	250	RC	A9270	CPT				Both			172.24	77.51	0.01	155.02	0.01							Fee Schedule		127.46							Fee Schedule																				0.08							Fee Schedule		155.02							Fee Schedule		0.09							Fee Schedule		0.07							Fee Schedule											0.09							Fee Schedule		0.07							Fee Schedule		
XR BARIUM NECTAR POLIBAR PLUS  705667	270	RC						Both			42	18.9	0.07	37.8	27.3							Fee Schedule		31.08							Fee Schedule																				0.08							Fee Schedule		37.8							Fee Schedule		0.09							Fee Schedule		0.07							Fee Schedule											0.09							Fee Schedule		0.07							Fee Schedule		
XR EZ HD BARIUM 340 705693	270	RC						Both			15	6.75	0.07	13.5	9.75							Fee Schedule		11.1							Fee Schedule																				0.08							Fee Schedule		13.5							Fee Schedule		0.09							Fee Schedule		0.07							Fee Schedule											0.09							Fee Schedule		0.07							Fee Schedule		
XR MAMMO 8 MR BX SITE ID # MRM4008	272	RC						Both			422	189.9	189.9	379.8	274.3							Fee Schedule		312.28							Fee Schedule																													379.8							Fee Schedule																																															
XR TUBING W/MALE LUER ADAPTER 601281	272	RC						Both			17	7.65	7.65	15.3	11.05							Fee Schedule		12.58							Fee Schedule																													15.3							Fee Schedule																																															
X-RAY GAUZE 4X4 #7317	272	RC						Both			2	0.9	0.9	1.8	1.3							Fee Schedule		1.48							Fee Schedule																													1.8							Fee Schedule																																															
XTRASORB 2.3X2.3 STERILE #86322 *DISC*	272	RC	A6234	CPT				Both			6.3	2.84	2.84	9.61	5.89							Fee Schedule		4.66							Fee Schedule		9.61							Fee Schedule		7.36							Fee Schedule											5.67							Fee Schedule																																															
XTRASORB 4X4 STERILE DRESSING 86344	272	RC						Both			12.6	5.67	5.67	11.34	8.19							Fee Schedule		9.32							Fee Schedule																													11.34							Fee Schedule																																															
XTRASORB 4X5 STERILE DRESSING 89545	272	RC	A6252	CPT				Both			8	3.6	2.94	7.2	2.94							Fee Schedule		5.92							Fee Schedule		4.78							Fee Schedule		3.67							Fee Schedule											7.2							Fee Schedule																																															
XTRASORB 8X8 STERILE DRESSING 86188	272	RC						Both			35.7	16.07	8.68	32.13	23.21							Fee Schedule		26.42							Fee Schedule																				9.33							Fee Schedule		32.13							Fee Schedule		10.73							Fee Schedule		8.68							Fee Schedule											10.73							Fee Schedule		8.68							Fee Schedule		
XTRASORB DSG. 4X4 # 86144	272	RC	A6210	CPT				Both			10.5	4.73	4.73	29.25	17.94							Fee Schedule		7.77							Fee Schedule		29.25							Fee Schedule		22.42							Fee Schedule											9.45							Fee Schedule																																															
XTRASORB DSG. 6X6 # 86266	272	RC	A6213	CPT				Both			21	9.45	4.32	18.9	11.16							Fee Schedule		15.54							Fee Schedule																				4.64							Fee Schedule		18.9							Fee Schedule		5.34							Fee Schedule		4.32							Fee Schedule											5.34							Fee Schedule		4.32							Fee Schedule		
XYLENE URINE 30443	301	RC	84999	CPT				Both			147	66.15	66.15	132.3	95.55							Fee Schedule									Other	No Additional Reimbursement 																												132.3							Fee Schedule																																															
XYLOCAINE 1&2 PLAIN	250	RC						Both			4.2	1.89	1.89	32.66	2.73							Fee Schedule		3.11							Fee Schedule																				28.4							Fee Schedule		3.78							Fee Schedule		32.66							Fee Schedule		26.41							Fee Schedule											32.66							Fee Schedule		26.41							Fee Schedule		
XYLOCAINE 10% ORAL SPRAY	250	RC						Both			4.2	1.89	1.89	3.78	2.73							Fee Schedule		3.11							Fee Schedule																													3.78							Fee Schedule																																															
XYLOCAINE 2 BOTTLE	250	RC						Both			16.19	7.29	7.29	14.57	10.52							Fee Schedule		11.98							Fee Schedule																													14.57							Fee Schedule																																															
XYLOCAINE 2 GM 50 ML W/O	250	RC						Both			3.78	1.7	1.7	3.4	2.46							Fee Schedule		2.8							Fee Schedule																													3.4							Fee Schedule																																															
XYLOCAINE 2% JELLY-30ML	250	RC	A9270	CPT				Both			52.5	23.63	0.01	47.25	0.01							Fee Schedule		38.85							Fee Schedule																													47.25							Fee Schedule																																															
XYLOCAINE 2% JELLY-5ML	250	RC	A9270	CPT				Both			22.05	9.92	0.01	19.85	0.01							Fee Schedule		16.32							Fee Schedule																													19.85							Fee Schedule																																															
"XYLOCAINE 2%/EPI.1/100,000-20ML"	250	RC	A9270	CPT				Both			11.55	5.2	0.01	10.4	0.01							Fee Schedule		8.55							Fee Schedule																													10.4							Fee Schedule																																															
XYLOCAINE 5 SPINAL	250	RC						Both			14.7	6.62	6.62	13.23	9.56							Fee Schedule		10.88							Fee Schedule																													13.23							Fee Schedule																																															
XYLOCAINE JELLY:1/2	250	RC	A9270	CPT				Both			39.9	17.96	0.01	35.91	0.01							Fee Schedule		29.53							Fee Schedule																													35.91							Fee Schedule																																															
XYLOCAINE VISC 2CC	250	RC	A9270	CPT				Both			22.05	9.92	0.01	19.85	0.01							Fee Schedule		16.32							Fee Schedule																													19.85							Fee Schedule																																															
XYLOCAINE/EPI 2%-0.002% 1.8ML INJ	250	RC						Both			11.55	5.2	5.2	10.4	7.51							Fee Schedule		8.55							Fee Schedule																													10.4							Fee Schedule																																															
XYLOCAINE:2% JELLY	250	RC	A9270	CPT				Both			39.38	17.72	0.01	35.44	0.01							Fee Schedule		29.14							Fee Schedule																													35.44							Fee Schedule																																															
XYLOCAINE-MPF-0.5%-50ML SDV	250	RC	A9270	CPT				Both			10.5	4.73	0.01	9.45	0.01							Fee Schedule		7.77							Fee Schedule																													9.45							Fee Schedule																																															
XYLOCAINE-MPF-1%-30 ML SDV	250	RC	A9270	CPT				Both			42.45	19.1	0.01	38.21	0.01							Fee Schedule		31.41							Fee Schedule																													38.21							Fee Schedule																																															
XYLOCAINE-MPF-2%-10ML SDV	250	RC	J2003	CPT				Both			6.3	2.84	2.84	5.67	4.1							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
XYLOCAINE-W/EPI 2%-0.0005%-20ML SDV	250	RC	J2004	CPT				Both			6.3	2.84	2.84	5.67	4.1							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
YANKAUER INFANT BE470	272	RC						Both			196	88.2	88.2	176.4	127.4							Fee Schedule		145.04							Fee Schedule																													176.4							Fee Schedule																																															
YANKAUER SUCTION	272	RC						Both			9.45	4.25	4.25	8.51	6.14							Fee Schedule		6.99							Fee Schedule																													8.51							Fee Schedule																																															
YANKAUER SUCTION	272	RC						Both			9.45	4.25	4.25	8.51	6.14							Fee Schedule		6.99							Fee Schedule																													8.51							Fee Schedule																																															
YANKAUER SUCTION TIPS STERILE	272	RC						Both			2	0.9	0.9	1.8	1.3							Fee Schedule		1.48							Fee Schedule																													1.8							Fee Schedule																																															
YANKAUER SUCTIONS #CFK83A	272	RC	A7002	CPT				Both			4	1.8	1.8	4.79	2.93							Fee Schedule		2.96							Fee Schedule		4.79							Fee Schedule																				3.6							Fee Schedule																																															
YUEH CATH & NEEDLE  COK228672	272	RC						Both			135.45	60.95	60.95	121.91	88.04							Fee Schedule		100.23							Fee Schedule																													121.91							Fee Schedule																																															
Z DRAPES MEDLINE #DYNJE4050	272	RC						Both			5	2.25	2.25	4.5	3.25							Fee Schedule		3.7							Fee Schedule																													4.5							Fee Schedule																																															
Z.IPPB SUB DUONEB	412	RC	94640	CPT				Both			283.5	127.58	4.32	286	175							Per Diem		209.79							Fee Schedule											12.53							Fee Schedule		4.65							Fee Schedule		255.15							Fee Schedule		5.35							Fee Schedule		4.32							Fee Schedule		286							Case Rate		5.35							Fee Schedule		4.32							Fee Schedule		
Z.IPPB SUB W/0.63 XOPENEX	412	RC	94640	CPT				Both			283.5	127.58	12.53	286	175							Per Diem		209.79							Fee Schedule											12.53							Fee Schedule											255.15							Fee Schedule																				286							Case Rate																				
Z.IPPB SUB W/O.31 XOPENEX	412	RC	94640	CPT				Both			283.5	127.58	12.53	286	175							Per Diem		209.79							Fee Schedule											12.53							Fee Schedule											255.15							Fee Schedule																				286							Case Rate																				
Z.IPPB SUB W/PROVENTIL	412	RC	94640	CPT				Both			283.5	127.58	12.53	286	175							Per Diem		209.79							Fee Schedule											12.53							Fee Schedule											255.15							Fee Schedule																				286							Case Rate																				
Z.IPPB SUB W/XOPENEX 1.25	412	RC	94640	CPT				Both			283.5	127.58	12.53	286	175							Per Diem		209.79							Fee Schedule											12.53							Fee Schedule											255.15							Fee Schedule																				286							Case Rate																				
ZAFIRLUKAST (ACCOLATE) 20MG TABLET	250	RC	A9270	CPT				Both			7.35	3.31	0.01	6.62	0.01							Fee Schedule		5.44							Fee Schedule																													6.62							Fee Schedule																																															
ZALEPLON 5 MG CAPSULE UD	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
ZANTAC 50 MG/2ML INJ	636	RC	J2780	CPT				Both			12.57	5.66	5.66	11.31		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	9.3							Fee Schedule																													11.31							Fee Schedule																																															
ZANTAC 50 MG/50 ML PREMIX	636	RC	J2780	CPT				Both			18.62	8.38	8.38	16.76		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	13.78							Fee Schedule																													16.76							Fee Schedule																																															
ZANTAC EFFERVESCENT 150 MG TABLET	250	RC	A9270	CPT				Both			5.39	2.43	0.01	4.85	0.01							Fee Schedule		3.99							Fee Schedule																													4.85							Fee Schedule																																															
ZANTAC:GELCAP 150MG	250	RC	A9270	CPT				Both			3.06	1.38	0.01	2.75	0.01							Fee Schedule		2.26							Fee Schedule																													2.75							Fee Schedule																																															
ZENIGEL-AG SILVER GEL 1.5OZ #100015-AG	272	RC	A6248	CPT				Both			12	5.4	5.4	23.84	14.63							Fee Schedule		8.88							Fee Schedule		23.84							Fee Schedule		18.29							Fee Schedule											10.8							Fee Schedule																																															
ZENIMEDICAL ZENIFOAM 4X4 #30044	272	RC	A6212	CPT				Both			6	2.7	2.7	14.26	8.74							Fee Schedule		4.44							Fee Schedule		14.26							Fee Schedule		10.93							Fee Schedule											5.4							Fee Schedule																																															
ZENIMEDICAL ZENIFOAM 6X6 #30066	272	RC	A6213	CPT				Both			9	4.05	4.05	11.16	11.16							Fee Schedule		6.66							Fee Schedule																													8.1							Fee Schedule																																															
ZENIMEDICAL ZENIFOAM HEEL #30000-H	272	RC	A6213	CPT				Both			15.75	7.09	7.09	26.62	11.16							Fee Schedule		11.66							Fee Schedule																				23.15							Fee Schedule		14.18							Fee Schedule		26.62							Fee Schedule		21.53							Fee Schedule											26.62							Fee Schedule		21.53							Fee Schedule		
ZENIMEDICAL ZENIFOAM SACRAL 7X7 #30077-S	272	RC	A6214	CPT				Both			17	7.65	7.65	15.92	9.26							Fee Schedule		12.58							Fee Schedule		15.12							Fee Schedule		11.58							Fee Schedule		13.84							Fee Schedule		15.3							Fee Schedule		15.92							Fee Schedule		12.87							Fee Schedule											15.92							Fee Schedule		12.87							Fee Schedule		
ZENIMEDICAL ZENIFOAM SACRAL 9X9 #30099-S	272	RC	A6214	CPT				Both			22.05	9.92	9.26	19.85	9.26							Fee Schedule		16.32							Fee Schedule		15.12							Fee Schedule		11.58							Fee Schedule											19.85							Fee Schedule																																															
ZERBAXA 1.5GM VIAL	636	RC	J0695	CPT				Both			571.14	257.01	8.84	514.03		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	8.84							Fee Schedule		9.22							Fee Schedule																				514.03							Fee Schedule																																															
ZERBAXA 1.5GM/NS 100ML	636	RC	J0695	CPT				Both			571.14	257.01	8.84	514.03		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	8.84							Fee Schedule		9.22							Fee Schedule											14.68							Fee Schedule		514.03							Fee Schedule		16.88							Fee Schedule		13.65							Fee Schedule											16.88							Fee Schedule		13.65							Fee Schedule		
ZERBAXA 3GM/NS 100ML	636	RC	J0695	CPT				Both			571.14	257.01	8.84	514.03		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	8.84							Fee Schedule		9.22							Fee Schedule											14.68							Fee Schedule		514.03							Fee Schedule		16.88							Fee Schedule		13.65							Fee Schedule											16.88							Fee Schedule		13.65							Fee Schedule		
ZERO TIP RETRIEVAL BASKET #NT4F19115	272	RC						Both			592	266.4	8.32	532.8	384.8							Fee Schedule		438.08							Fee Schedule																				8.95							Fee Schedule		532.8							Fee Schedule		10.29							Fee Schedule		8.32							Fee Schedule											10.29							Fee Schedule		8.32							Fee Schedule		
ZERO TIP RETRIEVAL BASKET M0063901000	272	RC						Both			613	275.85	8.32	551.7	398.45							Fee Schedule		453.62							Fee Schedule																				8.95							Fee Schedule		551.7							Fee Schedule		10.29							Fee Schedule		8.32							Fee Schedule											10.29							Fee Schedule		8.32							Fee Schedule		
ZERO TIP RETRIEVAL BASKET M0063901040	272	RC						Both			664	298.8	8.32	597.6	431.6							Fee Schedule		491.36							Fee Schedule																				8.95							Fee Schedule		597.6							Fee Schedule		10.29							Fee Schedule		8.32							Fee Schedule											10.29							Fee Schedule		8.32							Fee Schedule		
ZIMM  CANCELLOUS SCREW 4840-016-00	278	RC	C1713	CPT				Both			40.95	18.43	18.43	36.86		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	30.3							Fee Schedule																													36.86							Fee Schedule																																															
ZIMM  CONICAL 2359-16-25	278	RC						Both			242.55	109.15	109.15	218.3		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	179.49							Fee Schedule																													218.3							Fee Schedule																																															
ZIMM  LOCKING SCREW 2359-012-35	278	RC	C1713	CPT				Both			286.65	128.99	128.99	257.99		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	212.12							Fee Schedule																													257.99							Fee Schedule																																															
ZIMM  LOCKING SCREW 2359-016-35	278	RC	C1713	CPT				Both			298.2	134.19	134.19	268.38		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	220.67							Fee Schedule																													268.38							Fee Schedule																																															
ZIMM  LOCKING SCREW 2359-020-35	278	RC	C1713	CPT				Both			286.65	128.99	128.99	257.99		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	212.12							Fee Schedule																													257.99							Fee Schedule																																															
ZIMM  LOCKING SCREW 2359-18-24	278	RC	C1713	CPT				Both			298.2	134.19	134.19	268.38		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	220.67							Fee Schedule																													268.38							Fee Schedule																																															
ZIMM  LOCKING SCREW 2359-24-24	278	RC	C1713	CPT				Both			298.2	134.19	134.19	268.38		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	220.67							Fee Schedule																													268.38							Fee Schedule																																															
ZIMM  LOCKING SCREW 2359-38-35	278	RC	C1713	CPT				Both			288.75	129.94	129.94	259.88		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	213.68							Fee Schedule																													259.88							Fee Schedule																																															
ZIMM  LOCKING SCREW 2359-40-35	278	RC	C1713	CPT				Both			288.75	129.94	129.94	259.88		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	213.68							Fee Schedule																													259.88							Fee Schedule																																															
ZIMM  LOCKING SCREW 2359-46-35	278	RC	C1713	CPT				Both			288.75	129.94	129.94	259.88		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	213.68							Fee Schedule																													259.88							Fee Schedule																																															
ZIMM 1.25 K WIRE 4901-012-15	278	RC						Both			187.95	84.58	84.58	169.16		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	139.08							Fee Schedule																													169.16							Fee Schedule																																															
ZIMM 1/3 TUBULAR PLATE 2 HOLE	278	RC						Both			90.3	40.64	40.64	81.27		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	66.82							Fee Schedule																													81.27							Fee Schedule																																															
ZIMM 1/3 TUBULAR PLATE 3 HOLE	278	RC						Both			90.3	40.64	40.64	81.27		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	66.82							Fee Schedule																													81.27							Fee Schedule																																															
ZIMM 1/3 TUBULAR PLATE 4 HOLE	278	RC						Both			90.3	40.64	40.64	81.27		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	66.82							Fee Schedule																													81.27							Fee Schedule																																															
ZIMM 1/3 TUBULAR PLATE 5 HOLE	278	RC						Both			90.3	40.64	40.64	81.27		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	66.82							Fee Schedule																													81.27							Fee Schedule																																															
ZIMM 1/3 TUBULAR PLATE 6 HOLE	278	RC						Both			90.3	40.64	40.64	81.27		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	66.82							Fee Schedule																													81.27							Fee Schedule																																															
ZIMM 1/3 TUBULAR PLATE 7 HOLE	278	RC						Both			90.3	40.64	40.64	81.27		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	66.82							Fee Schedule																													81.27							Fee Schedule																																															
ZIMM 1/3 TUBULAR PLATE 8 HOLE	278	RC						Both			90.3	40.64	40.64	81.27		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	66.82							Fee Schedule																													81.27							Fee Schedule																																															
ZIMM 1/4 TUBE PLATE 3 HOLE	278	RC						Both			102.9	46.31	46.31	92.61		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	76.15							Fee Schedule																													92.61							Fee Schedule																																															
ZIMM 1/4 TUBE PLATE 4 HOLE	278	RC						Both			119.7	53.87	53.87	107.73		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	88.58							Fee Schedule																													107.73							Fee Schedule																																															
ZIMM 1/4 TUBE PLATE 5 HOLE	278	RC						Both			119.7	53.87	53.87	107.73		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	88.58							Fee Schedule																													107.73							Fee Schedule																																															
ZIMM 1/4 TUBE PLATE 6 HOLE	278	RC						Both			122.85	55.28	55.28	110.57		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	90.91							Fee Schedule																													110.57							Fee Schedule																																															
ZIMM 1/4 TUBE PLATE 7 HOLE	278	RC						Both			122.85	55.28	55.28	110.57		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	90.91							Fee Schedule																													110.57							Fee Schedule																																															
ZIMM 1/4 TUBE PLATE 8 HOLE	278	RC						Both			128.1	57.65	57.65	115.29		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	94.79							Fee Schedule																													115.29							Fee Schedule																																															
ZIMM 3.5 CANCELLOUS 14MM	278	RC	C1713	CPT				Both			35.7	16.07	16.07	32.13		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	26.42							Fee Schedule																													32.13							Fee Schedule																																															
ZIMM 3.5 CANCELLOUS 16MM	278	RC	C1713	CPT				Both			35.7	16.07	16.07	32.13		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	26.42							Fee Schedule																													32.13							Fee Schedule																																															
ZIMM 3.5 CANCELLOUS 18MM	278	RC	C1713	CPT				Both			35.7	16.07	16.07	32.13		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	26.42							Fee Schedule																													32.13							Fee Schedule																																															
ZIMM 3.5 CANCELLOUS 20MM	278	RC	C1713	CPT				Both			35.7	16.07	16.07	32.13		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	26.42							Fee Schedule																													32.13							Fee Schedule																																															
ZIMM 3.5 CORTICAL FINE THRD 10MM	278	RC	C1713	CPT				Both			34.65	15.59	15.59	31.19		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	25.64							Fee Schedule																													31.19							Fee Schedule																																															
ZIMM 3.5 CORTICAL FINE THRD 12MM	278	RC	C1713	CPT				Both			34.65	15.59	15.59	31.19		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	25.64							Fee Schedule																													31.19							Fee Schedule																																															
ZIMM 3.5 CORTICAL FINE THRD 14MM	278	RC	C1713	CPT				Both			34.65	15.59	15.59	31.19		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	25.64							Fee Schedule																													31.19							Fee Schedule																																															
ZIMM 3.5 CORTICAL FINE THRD 16MM	278	RC	C1713	CPT				Both			34.65	15.59	15.59	31.19		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	25.64							Fee Schedule																													31.19							Fee Schedule																																															
ZIMM 3.5 CORTICAL FINE THRD 18MM	278	RC	C1713	CPT				Both			34.65	15.59	15.59	31.19		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	25.64							Fee Schedule																													31.19							Fee Schedule																																															
ZIMM 3.5 CORTICAL FINE THRD 20MM	278	RC	C1713	CPT				Both			34.65	15.59	15.59	31.19		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	25.64							Fee Schedule																													31.19							Fee Schedule																																															
ZIMM 3.5 CORTICAL FINE THRD 22MM	278	RC	C1713	CPT				Both			34.65	15.59	15.59	31.19		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	25.64							Fee Schedule																													31.19							Fee Schedule																																															
ZIMM 3.5 CORTICAL FINE THRD 24MM	278	RC	C1713	CPT				Both			34.65	15.59	15.59	31.19		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	25.64							Fee Schedule																													31.19							Fee Schedule																																															
ZIMM 3.5 CORTICAL FINE THRD 26MM	278	RC	C1713	CPT				Both			34.65	15.59	15.59	31.19		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	25.64							Fee Schedule																													31.19							Fee Schedule																																															
ZIMM 3.5 CORTICAL FINE THRD 28MM	278	RC	C1713	CPT				Both			34.65	15.59	15.59	31.19		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	25.64							Fee Schedule																													31.19							Fee Schedule																																															
ZIMM 3.5 CORTICAL FINE THRD 30MM	278	RC	C1713	CPT				Both			34.65	15.59	15.59	31.19		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	25.64							Fee Schedule																													31.19							Fee Schedule																																															
ZIMM 3.5 CORTICAL FINE THRD 36MM	278	RC	C1713	CPT				Both			34.65	15.59	15.59	31.19		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	25.64							Fee Schedule																													31.19							Fee Schedule																																															
ZIMM 3.5 CORTICAL FINE THRD 40MM	278	RC	C1713	CPT				Both			34.65	15.59	15.59	31.19		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	25.64							Fee Schedule																													31.19							Fee Schedule																																															
ZIMM 3.5 CORTICAL SCREW 2347-20-30	278	RC	C1713	CPT				Both			90.3	40.64	40.64	81.27		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	66.82							Fee Schedule																													81.27							Fee Schedule																																															
ZIMM 3.5 CORTICAL SCREW 2347-20-32	278	RC	C1713	CPT				Both			90.3	40.64	40.64	81.27		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	66.82							Fee Schedule																													81.27							Fee Schedule																																															
ZIMM 3.5 CORTICAL SCREW 2347-22-28	278	RC	C1713	CPT				Both			90.3	40.64	40.64	81.27		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	66.82							Fee Schedule																													81.27							Fee Schedule																																															
ZIMM 3.5 CORTICAL SCREW 2348-14-35	278	RC	C1713	CPT				Both			107.1	48.2	48.2	96.39		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	79.25							Fee Schedule																													96.39							Fee Schedule																																															
ZIMM 3.5 CORTICAL SCREW 2348-16-35	278	RC	C1713	CPT				Both			107.1	48.2	48.2	96.39		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	79.25							Fee Schedule																													96.39							Fee Schedule																																															
ZIMM 3.5 CORTICAL SCREW 2348-18-35	278	RC	C1713	CPT				Both			107.1	48.2	48.2	96.39		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	79.25							Fee Schedule																													96.39							Fee Schedule																																															
ZIMM 4.0 CANCELLOUS 10MM	278	RC	C1713	CPT				Both			34.65	15.59	15.59	31.19		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	25.64							Fee Schedule																													31.19							Fee Schedule																																															
ZIMM 4.0 CANCELLOUS 12MM	278	RC	C1713	CPT				Both			34.65	15.59	15.59	31.19		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	25.64							Fee Schedule																													31.19							Fee Schedule																																															
ZIMM 4.0 CANCELLOUS 14MM	278	RC	C1713	CPT				Both			34.65	15.59	15.59	31.19		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	25.64							Fee Schedule																													31.19							Fee Schedule																																															
ZIMM 4.0 CANCELLOUS 16MM	278	RC	C1713	CPT				Both			34.65	15.59	15.59	31.19		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	25.64							Fee Schedule																													31.19							Fee Schedule																																															
ZIMM 4.0 CANCELLOUS 18MM	278	RC	C1713	CPT				Both			34.65	15.59	15.59	31.19		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	25.64							Fee Schedule																													31.19							Fee Schedule																																															
ZIMM 4.0 CANCELLOUS 20MM	278	RC	C1713	CPT				Both			34.65	15.59	15.59	31.19		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	25.64							Fee Schedule																													31.19							Fee Schedule																																															
ZIMM 4.0 CANCELLOUS 22MM	278	RC	C1713	CPT				Both			34.65	15.59	15.59	31.19		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	25.64							Fee Schedule																													31.19							Fee Schedule																																															
ZIMM 4.0 CANCELLOUS 24MM	278	RC	C1713	CPT				Both			34.65	15.59	15.59	31.19		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	25.64							Fee Schedule																													31.19							Fee Schedule																																															
ZIMM 4.0 CANCELLOUS 26MM	278	RC	C1713	CPT				Both			34.65	15.59	15.59	31.19		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	25.64							Fee Schedule																													31.19							Fee Schedule																																															
ZIMM 4.0 CANCELLOUS 28MM	278	RC	C1713	CPT				Both			34.65	15.59	15.59	31.19		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	25.64							Fee Schedule																													31.19							Fee Schedule																																															
ZIMM 4.0 CANCELLOUS 30MM	278	RC	C1713	CPT				Both			34.65	15.59	15.59	31.19		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	25.64							Fee Schedule																													31.19							Fee Schedule																																															
ZIMM 4.0 CANCELLOUS 35MM	278	RC	C1713	CPT				Both			34.65	15.59	15.59	31.19		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	25.64							Fee Schedule																													31.19							Fee Schedule																																															
ZIMM 4.0 CANCELLOUS 40MM	278	RC	C1713	CPT				Both			34.65	15.59	15.59	31.19		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	25.64							Fee Schedule																													31.19							Fee Schedule																																															
ZIMM 4.0 CANCELLOUS 45MM	278	RC	C1713	CPT				Both			34.65	15.59	15.59	31.19		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	25.64							Fee Schedule																													31.19							Fee Schedule																																															
ZIMM 4.0 CANCELLOUS 50MM	278	RC	C1713	CPT				Both			34.65	15.59	15.59	31.19		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	25.64							Fee Schedule																													31.19							Fee Schedule																																															
ZIMM 4.0 CANCELLOUS SCREW 2480-12-41	278	RC	C1713	CPT				Both			164.85	74.18	74.18	148.37		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	121.99							Fee Schedule																													148.37							Fee Schedule																																															
ZIMM 4.0 CANCELLOUS SCREW 2480-16-41	278	RC	C1713	CPT				Both			164.85	74.18	74.18	148.37		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	121.99							Fee Schedule																													148.37							Fee Schedule																																															
ZIMM 4.5 CORT SELF TAPPING SCREW 24MM	278	RC	C1713	CPT				Both			24.15	10.87	10.87	21.74		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	17.87							Fee Schedule																													21.74							Fee Schedule																																															
ZIMM 4.5 CORT SELF TAPPING SCREW 26MM	278	RC	C1713	CPT				Both			56.7	25.52	25.52	51.03		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	41.96							Fee Schedule																													51.03							Fee Schedule																																															
ZIMM 4.5 CORT SELF TAPPING SCREW 28MM	278	RC	C1713	CPT				Both			56.7	25.52	25.52	51.03		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	41.96							Fee Schedule																													51.03							Fee Schedule																																															
ZIMM 4.5 CORT SELF TAPPING SCREW 30MM	278	RC	C1713	CPT				Both			56.7	25.52	25.52	51.03		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	41.96							Fee Schedule																													51.03							Fee Schedule																																															
ZIMM 4.5 CORT SELF TAPPING SCREW 32MM	278	RC	C1713	CPT				Both			56.7	25.52	25.52	51.03		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	41.96							Fee Schedule																													51.03							Fee Schedule																																															
ZIMM 4.5 CORT SELF TAPPING SCREW 34MM	278	RC	C1713	CPT				Both			37.8	17.01	17.01	34.02		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	27.97							Fee Schedule																													34.02							Fee Schedule																																															
ZIMM 4.5 CORT SELF TAPPING SCREW 36MM	278	RC	C1713	CPT				Both			37.8	17.01	17.01	34.02		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	27.97							Fee Schedule																													34.02							Fee Schedule																																															
ZIMM 4.5 CORT SELF TAPPING SCREW 38MM	278	RC	C1713	CPT				Both			37.8	17.01	17.01	34.02		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	27.97							Fee Schedule																													34.02							Fee Schedule																																															
ZIMM 4.5 CORT SELF TAPPING SCREW 40MM	278	RC	C1713	CPT				Both			37.8	17.01	17.01	34.02		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	27.97							Fee Schedule																													34.02							Fee Schedule																																															
ZIMM 4.5 CORT SELF TAPPING SCREW 42MM	278	RC	C1713	CPT				Both			37.8	17.01	17.01	34.02		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	27.97							Fee Schedule																													34.02							Fee Schedule																																															
ZIMM 4.5 CORT SELF TAPPING SCREW 44MM	278	RC	C1713	CPT				Both			37.8	17.01	17.01	34.02		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	27.97							Fee Schedule																													34.02							Fee Schedule																																															
ZIMM 4.5 CORT SELF TAPPING SCREW 46MM	278	RC	C1713	CPT				Both			37.8	17.01	17.01	34.02		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	27.97							Fee Schedule																													34.02							Fee Schedule																																															
ZIMM 4.5 CORT SELF TAPPING SCREW 48MM	278	RC	C1713	CPT				Both			37.8	17.01	17.01	34.02		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	27.97							Fee Schedule																													34.02							Fee Schedule																																															
ZIMM 4.5 CORT SELF TAPPING SCREW 50MM	278	RC	C1713	CPT				Both			37.8	17.01	17.01	34.02		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	27.97							Fee Schedule																													34.02							Fee Schedule																																															
ZIMM 4.5 CORT SELF TAPPING SCREW 52MM	278	RC	C1713	CPT				Both			37.8	17.01	17.01	34.02		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	27.97							Fee Schedule																													34.02							Fee Schedule																																															
ZIMM 4.5 CORT SELF TAPPING SCREW 54MM	278	RC	C1713	CPT				Both			37.8	17.01	17.01	34.02		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	27.97							Fee Schedule																													34.02							Fee Schedule																																															
ZIMM 4.5 CORT SELF TAPPING SCREW 56MM	278	RC	C1713	CPT				Both			37.8	17.01	17.01	34.02		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	27.97							Fee Schedule																													34.02							Fee Schedule																																															
ZIMM 4.5 CORT SELF TAPPING SCREW 58MM	278	RC	C1713	CPT				Both			37.8	17.01	17.01	34.02		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	27.97							Fee Schedule																													34.02							Fee Schedule																																															
ZIMM 4.5 CORT SELF TAPPING SCREW 60MM	278	RC	C1713	CPT				Both			37.8	17.01	17.01	34.02		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	27.97							Fee Schedule																													34.02							Fee Schedule																																															
ZIMM 4.5 CORTICAL 14MM	278	RC	C1713	CPT				Both			33.6	15.12	15.12	30.24		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	24.86							Fee Schedule																													30.24							Fee Schedule																																															
ZIMM 4.5 CORTICAL 16MM	278	RC	C1713	CPT				Both			33.6	15.12	15.12	30.24		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	24.86							Fee Schedule																													30.24							Fee Schedule																																															
ZIMM 4.5 CORTICAL 18MM	278	RC	C1713	CPT				Both			33.6	15.12	15.12	30.24		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	24.86							Fee Schedule																													30.24							Fee Schedule																																															
ZIMM 4.5 CORTICAL 20MM	278	RC	C1713	CPT				Both			37.8	17.01	17.01	34.02		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	27.97							Fee Schedule																													34.02							Fee Schedule																																															
ZIMM 4.5 CORTICAL 22MM	278	RC	C1713	CPT				Both			37.8	17.01	17.01	34.02		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	27.97							Fee Schedule																													34.02							Fee Schedule																																															
ZIMM 4.5 CORTICAL 24MM	278	RC	C1713	CPT				Both			37.8	17.01	17.01	34.02		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	27.97							Fee Schedule																													34.02							Fee Schedule																																															
ZIMM 4.5 CORTICAL 26MM	278	RC	C1713	CPT				Both			37.8	17.01	17.01	34.02		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	27.97							Fee Schedule																													34.02							Fee Schedule																																															
ZIMM 4.5 CORTICAL 28MM	278	RC	C1713	CPT				Both			37.8	17.01	17.01	34.02		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	27.97							Fee Schedule																													34.02							Fee Schedule																																															
ZIMM 4.5 CORTICAL 30MM	278	RC	C1713	CPT				Both			37.8	17.01	17.01	34.02		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	27.97							Fee Schedule																													34.02							Fee Schedule																																															
ZIMM 4.5 CORTICAL 32MM	278	RC	C1713	CPT				Both			37.8	17.01	17.01	34.02		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	27.97							Fee Schedule																													34.02							Fee Schedule																																															
ZIMM 4.5 CORTICAL 34MM	278	RC	C1713	CPT				Both			37.8	17.01	17.01	34.02		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	27.97							Fee Schedule																													34.02							Fee Schedule																																															
ZIMM 4.5 CORTICAL 36MM	278	RC	C1713	CPT				Both			37.8	17.01	17.01	34.02		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	27.97							Fee Schedule																													34.02							Fee Schedule																																															
ZIMM 4.5 CORTICAL 38MM	278	RC	C1713	CPT				Both			37.8	17.01	17.01	34.02		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	27.97							Fee Schedule																													34.02							Fee Schedule																																															
ZIMM 4.5 CORTICAL 40MM	278	RC	C1713	CPT				Both			37.8	17.01	17.01	34.02		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	27.97							Fee Schedule																													34.02							Fee Schedule																																															
ZIMM 4.5 CORTICAL 42MM	278	RC	C1713	CPT				Both			37.8	17.01	17.01	34.02		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	27.97							Fee Schedule																													34.02							Fee Schedule																																															
ZIMM 4.5 CORTICAL 44MM	278	RC	C1713	CPT				Both			37.8	17.01	17.01	34.02		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	27.97							Fee Schedule																													34.02							Fee Schedule																																															
ZIMM 4.5 CORTICAL 46MM	278	RC	C1713	CPT				Both			37.8	17.01	17.01	34.02		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	27.97							Fee Schedule																													34.02							Fee Schedule																																															
ZIMM 4.5 CORTICAL 48MM	278	RC	C1713	CPT				Both			37.8	17.01	17.01	34.02		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	27.97							Fee Schedule																													34.02							Fee Schedule																																															
ZIMM 4.5 CORTICAL 50MM	278	RC	C1713	CPT				Both			37.8	17.01	17.01	34.02		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	27.97							Fee Schedule																													34.02							Fee Schedule																																															
ZIMM 4.5 CORTICAL 52MM	278	RC	C1713	CPT				Both			37.8	17.01	17.01	34.02		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	27.97							Fee Schedule																													34.02							Fee Schedule																																															
ZIMM 4.5 CORTICAL 54MM	278	RC	C1713	CPT				Both			37.8	17.01	17.01	34.02		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	27.97							Fee Schedule																													34.02							Fee Schedule																																															
ZIMM 4.5 CORTICAL 56MM	278	RC	C1713	CPT				Both			37.8	17.01	17.01	34.02		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	27.97							Fee Schedule																													34.02							Fee Schedule																																															
ZIMM 4.5 CORTICAL 58MM	278	RC	C1713	CPT				Both			37.8	17.01	17.01	34.02		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	27.97							Fee Schedule																													34.02							Fee Schedule																																															
ZIMM 4.5 CORTICAL 60MM	278	RC	C1713	CPT				Both			37.8	17.01	17.01	34.02		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	27.97							Fee Schedule																													34.02							Fee Schedule																																															
ZIMM 4.5 CORTICAL 64MM	278	RC	C1713	CPT				Both			37.8	17.01	17.01	34.02		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	27.97							Fee Schedule																													34.02							Fee Schedule																																															
ZIMM 4.5 CORTICAL 70MM	278	RC	C1713	CPT				Both			37.8	17.01	17.01	34.02		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	27.97							Fee Schedule																													34.02							Fee Schedule																																															
ZIMM 4.5 MALLEOLAR 25MM	278	RC	C1713	CPT				Both			51.45	23.15	23.15	46.31		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	38.07							Fee Schedule																													46.31							Fee Schedule																																															
ZIMM 4.5 MALLEOLAR 30MM	278	RC	C1713	CPT				Both			51.45	23.15	23.15	46.31		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	38.07							Fee Schedule																													46.31							Fee Schedule																																															
ZIMM 4.5 MALLEOLAR 35MM	278	RC	C1713	CPT				Both			51.45	23.15	23.15	46.31		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	38.07							Fee Schedule																													46.31							Fee Schedule																																															
ZIMM 4.5 MALLEOLAR 40MM	278	RC	C1713	CPT				Both			51.45	23.15	23.15	46.31		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	38.07							Fee Schedule																													46.31							Fee Schedule																																															
ZIMM 4.5 MALLEOLAR 45MM	278	RC	C1713	CPT				Both			51.45	23.15	23.15	46.31		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	38.07							Fee Schedule																													46.31							Fee Schedule																																															
ZIMM 4.5 MALLEOLAR 50MM	278	RC	C1713	CPT				Both			51.45	23.15	23.15	46.31		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	38.07							Fee Schedule																													46.31							Fee Schedule																																															
ZIMM 4.5 MALLEOLAR 55MM	278	RC	C1713	CPT				Both			51.45	23.15	23.15	46.31		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	38.07							Fee Schedule																													46.31							Fee Schedule																																															
ZIMM 4.5 MALLEOLAR 60MM	278	RC	C1713	CPT				Both			51.45	23.15	23.15	46.31		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	38.07							Fee Schedule																													46.31							Fee Schedule																																															
ZIMM 4.5 MALLEOLAR 65MM	278	RC	C1713	CPT				Both			51.45	23.15	23.15	46.31		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	38.07							Fee Schedule																													46.31							Fee Schedule																																															
ZIMM 4.5 MALLEOLAR 70MM	278	RC	C1713	CPT				Both			51.45	23.15	23.15	46.31		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	38.07							Fee Schedule																													46.31							Fee Schedule																																															
ZIMM 6.5 CANCELL LNG THREAD 100MM	278	RC	C1713	CPT				Both			219.45	98.75	98.75	197.51		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	162.39							Fee Schedule																													197.51							Fee Schedule																																															
ZIMM 6.5 CANCELL LNG THREAD 110MM	278	RC	C1713	CPT				Both			219.45	98.75	98.75	197.51		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	162.39							Fee Schedule																													197.51							Fee Schedule																																															
ZIMM 6.5 CANCELL LNG THREAD 30MM	278	RC	C1713	CPT				Both			219.45	98.75	98.75	197.51		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	162.39							Fee Schedule																													197.51							Fee Schedule																																															
ZIMM 6.5 CANCELL LNG THREAD 35MM	278	RC	C1713	CPT				Both			219.45	98.75	98.75	197.51		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	162.39							Fee Schedule																													197.51							Fee Schedule																																															
ZIMM 6.5 CANCELL LNG THREAD 40MM	278	RC	C1713	CPT				Both			219.45	98.75	98.75	197.51		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	162.39							Fee Schedule																													197.51							Fee Schedule																																															
ZIMM 6.5 CANCELL LNG THREAD 45MM	278	RC	C1713	CPT				Both			219.45	98.75	98.75	197.51		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	162.39							Fee Schedule																													197.51							Fee Schedule																																															
ZIMM 6.5 CANCELL LNG THREAD 50MM	278	RC	C1713	CPT				Both			219.45	98.75	98.75	197.51		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	162.39							Fee Schedule																													197.51							Fee Schedule																																															
ZIMM 6.5 CANCELL LNG THREAD 55MM	278	RC	C1713	CPT				Both			219.45	98.75	98.75	197.51		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	162.39							Fee Schedule																													197.51							Fee Schedule																																															
ZIMM 6.5 CANCELL LNG THREAD 60MM	278	RC	C1713	CPT				Both			219.45	98.75	98.75	197.51		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	162.39							Fee Schedule																													197.51							Fee Schedule																																															
ZIMM 6.5 CANCELL LNG THREAD 65MM	278	RC	C1713	CPT				Both			219.45	98.75	98.75	197.51		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	162.39							Fee Schedule																													197.51							Fee Schedule																																															
ZIMM 6.5 CANCELL LNG THREAD 70MM	278	RC	C1713	CPT				Both			219.45	98.75	98.75	197.51		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	162.39							Fee Schedule																													197.51							Fee Schedule																																															
ZIMM 6.5 CANCELL LNG THREAD 80MM	278	RC	C1713	CPT				Both			219.45	98.75	98.75	197.51		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	162.39							Fee Schedule																													197.51							Fee Schedule																																															
ZIMM 6.5 CANCELL LNG THREAD 90MM	278	RC	C1713	CPT				Both			219.45	98.75	98.75	197.51		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	162.39							Fee Schedule																													197.51							Fee Schedule																																															
ZIMM 6.5 CANCELLOUS SHORT THREAD 100MM	278	RC	C1713	CPT				Both			219.45	98.75	98.75	197.51		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	162.39							Fee Schedule																													197.51							Fee Schedule																																															
ZIMM 6.5 CANCELLOUS SHORT THREAD 105MM	278	RC	C1713	CPT				Both			219.45	98.75	98.75	197.51		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	162.39							Fee Schedule																													197.51							Fee Schedule																																															
ZIMM 6.5 CANCELLOUS SHORT THREAD 110MM	278	RC	C1713	CPT				Both			219.45	98.75	98.75	197.51		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	162.39							Fee Schedule																													197.51							Fee Schedule																																															
ZIMM 6.5 CANCELLOUS SHORT THREAD 25MM	278	RC	C1713	CPT				Both			219.45	98.75	98.75	197.51		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	162.39							Fee Schedule																													197.51							Fee Schedule																																															
ZIMM 6.5 CANCELLOUS SHORT THREAD 30MM	278	RC	C1713	CPT				Both			219.45	98.75	98.75	197.51		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	162.39							Fee Schedule																													197.51							Fee Schedule																																															
ZIMM 6.5 CANCELLOUS SHORT THREAD 35MM	278	RC	C1713	CPT				Both			219.45	98.75	98.75	197.51		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	162.39							Fee Schedule																													197.51							Fee Schedule																																															
ZIMM 6.5 CANCELLOUS SHORT THREAD 40MM	278	RC	C1713	CPT				Both			219.45	98.75	98.75	197.51		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	162.39							Fee Schedule																													197.51							Fee Schedule																																															
ZIMM 6.5 CANCELLOUS SHORT THREAD 45MM	278	RC	C1713	CPT				Both			219.45	98.75	98.75	197.51		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	162.39							Fee Schedule																													197.51							Fee Schedule																																															
ZIMM 6.5 CANCELLOUS SHORT THREAD 50MM	278	RC	C1713	CPT				Both			219.45	98.75	98.75	197.51		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	162.39							Fee Schedule																													197.51							Fee Schedule																																															
ZIMM 6.5 CANCELLOUS SHORT THREAD 55MM	278	RC	C1713	CPT				Both			219.45	98.75	98.75	197.51		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	162.39							Fee Schedule																													197.51							Fee Schedule																																															
ZIMM 6.5 CANCELLOUS SHORT THREAD 60MM	278	RC	C1713	CPT				Both			219.45	98.75	98.75	197.51		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	162.39							Fee Schedule																													197.51							Fee Schedule																																															
ZIMM 6.5 CANCELLOUS SHORT THREAD 65MM	278	RC	C1713	CPT				Both			219.45	98.75	98.75	197.51		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	162.39							Fee Schedule																													197.51							Fee Schedule																																															
ZIMM 6.5 CANCELLOUS SHORT THREAD 70MM	278	RC	C1713	CPT				Both			219.45	98.75	98.75	197.51		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	162.39							Fee Schedule																													197.51							Fee Schedule																																															
ZIMM 6.5 CANCELLOUS SHORT THREAD 75MM	278	RC	C1713	CPT				Both			219.45	98.75	98.75	197.51		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	162.39							Fee Schedule																													197.51							Fee Schedule																																															
ZIMM 6.5 CANCELLOUS SHORT THREAD 80MM	278	RC	C1713	CPT				Both			219.45	98.75	98.75	197.51		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	162.39							Fee Schedule																													197.51							Fee Schedule																																															
ZIMM 6.5 CANCELLOUS SHORT THREAD 85MM	278	RC	C1713	CPT				Both			219.45	98.75	98.75	197.51		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	162.39							Fee Schedule																													197.51							Fee Schedule																																															
ZIMM 6.5 CANCELLOUS SHORT THREAD 90MM	278	RC	C1713	CPT				Both			219.45	98.75	98.75	197.51		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	162.39							Fee Schedule																													197.51							Fee Schedule																																															
ZIMM 6.5 CANCELLOUS SHORT THREAD 95MM	278	RC	C1713	CPT				Both			219.45	98.75	98.75	197.51		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	162.39							Fee Schedule																													197.51							Fee Schedule																																															
ZIMM CANCEL. WASHERS FOR 6.5	278	RC						Both			37.8	17.01	17.01	34.02		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	27.97							Fee Schedule																													34.02							Fee Schedule																																															
ZIMM CAST 2''	271	RC						Both			24.15	10.87	10.87	21.74	15.7							Fee Schedule		17.87							Fee Schedule																													21.74							Fee Schedule																																															
ZIMM CAST 3''	271	RC						Both			29.93	13.47	13.47	26.94	19.45							Fee Schedule		22.15							Fee Schedule																													26.94							Fee Schedule																																															
ZIMM CAST 4''	271	RC						Both			39.38	17.72	17.72	35.44	25.6							Fee Schedule		29.14							Fee Schedule																													35.44							Fee Schedule																																															
ZIMM CAST 5''	271	RC						Both			48.3	21.74	21.74	43.47	31.4							Fee Schedule		35.74							Fee Schedule																													43.47							Fee Schedule																																															
ZIMM CLOVER LEAF PLATE 2452-104-04	278	RC						Both			140.7	63.32	63.32	126.63		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	104.12							Fee Schedule																													126.63							Fee Schedule																																															
ZIMM CLOVER LEAF PLATE 2452-88-03	278	RC						Both			140.7	63.32	63.32	126.63		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	104.12							Fee Schedule																													126.63							Fee Schedule																																															
ZIMM CORTICAL SCREW 4827-14-01	278	RC	C1713	CPT				Both			51.45	23.15	23.15	46.31		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	38.07							Fee Schedule																													46.31							Fee Schedule																																															
ZIMM CORTICAL SCREW 4827-16-01	278	RC	C1713	CPT				Both			51.45	23.15	23.15	46.31		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	38.07							Fee Schedule																													46.31							Fee Schedule																																															
ZIMM CORTICAL SCREW 4827-20-01	278	RC	C1713	CPT				Both			51.45	23.15	23.15	46.31		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	38.07							Fee Schedule																													46.31							Fee Schedule																																															
ZIMM CORTICAL SCREW 4835-014-01	278	RC	C1713	CPT				Both			51.45	23.15	23.15	46.31		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	38.07							Fee Schedule																													46.31							Fee Schedule																																															
ZIMM CORTICAL SCREW 4835-014-01	278	RC	C1713	CPT				Both			51.45	23.15	23.15	46.31		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	38.07							Fee Schedule																													46.31							Fee Schedule																																															
ZIMM CORTICAL SCREW 4835-016-01	278	RC	C1713	CPT				Both			51.45	23.15	23.15	46.31		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	38.07							Fee Schedule																													46.31							Fee Schedule																																															
ZIMM CORTICAL SCREW 4835-040-01	278	RC	C1713	CPT				Both			51.45	23.15	23.15	46.31		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	38.07							Fee Schedule																													46.31							Fee Schedule																																															
ZIMM FOREARM PLATE 10 HOLE	278	RC						Both			221.55	99.7	99.7	199.4		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	163.95							Fee Schedule																													199.4							Fee Schedule																																															
ZIMM FOREARM PLATE 5 HOLE	278	RC						Both			221.55	99.7	99.7	199.4		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	163.95							Fee Schedule																													199.4							Fee Schedule																																															
ZIMM FOREARM PLATE 6 HOLE	278	RC						Both			221.55	99.7	99.7	199.4		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	163.95							Fee Schedule																													199.4							Fee Schedule																																															
ZIMM FOREARM PLATE 7 HOLE	278	RC						Both			221.55	99.7	99.7	199.4		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	163.95							Fee Schedule																													199.4							Fee Schedule																																															
ZIMM FOREARM PLATE 8 HOLE	278	RC						Both			221.55	99.7	99.7	199.4		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	163.95							Fee Schedule																													199.4							Fee Schedule																																															
ZIMM FOREARM PLATE 9 HOLE	278	RC						Both			221.55	99.7	99.7	199.4		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	163.95							Fee Schedule																													199.4							Fee Schedule																																															
ZIMM GUIDE PIN  (COMPRESSION HIP)	272	RC						Both			51.45	23.15	23.15	46.31	33.44							Fee Schedule		38.07							Fee Schedule																													46.31							Fee Schedule																																															
ZIMM MINI EPIPHYSIS 2418 PLATE	278	RC						Both			102.9	46.31	46.31	92.61		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	76.15							Fee Schedule																													92.61							Fee Schedule																																															
ZIMM MINI EPIPHYSIS 2419 PLATE	278	RC						Both			102.9	46.31	46.31	92.61		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	76.15							Fee Schedule																													92.61							Fee Schedule																																															
ZIMM MINI FRAG 2455 SERIES 3 HOLE PLATE	278	RC						Both			102.9	46.31	46.31	92.61		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	76.15							Fee Schedule																													92.61							Fee Schedule																																															
ZIMM MINI FRAG 2455 SERIES 4 HOLE PLATE	278	RC						Both			119.7	53.87	53.87	107.73		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	88.58							Fee Schedule																													107.73							Fee Schedule																																															
ZIMM MINI FRAG 2455 SERIES 8 HOLE PLATE	278	RC						Both			128.1	57.65	57.65	115.29		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	94.79							Fee Schedule																													115.29							Fee Schedule																																															
ZIMM MINI STRAIGHT PLATE 2420 3 HOLE	278	RC						Both			102.9	46.31	46.31	92.61		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	76.15							Fee Schedule																													92.61							Fee Schedule																																															
ZIMM MINI STRAIGHT PLATE 2420 4 HOLE	278	RC						Both			119.7	53.87	53.87	107.73		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	88.58							Fee Schedule																													107.73							Fee Schedule																																															
ZIMM MINI STRAIGHT PLATE 2420 5 HOLE	278	RC						Both			119.7	53.87	53.87	107.73		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	88.58							Fee Schedule																													107.73							Fee Schedule																																															
ZIMM MINI STRAIGHT PLATE 2420 6 HOLE	278	RC						Both			122.85	55.28	55.28	110.57		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	90.91							Fee Schedule																													110.57							Fee Schedule																																															
ZIMM NARROW SCP PLATE 3  HOLE	278	RC						Both			256.2	115.29	115.29	230.58		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	189.59							Fee Schedule																													230.58							Fee Schedule																																															
ZIMM NARROW SCP PLATE 4  HOLE	278	RC						Both			256.2	115.29	115.29	230.58		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	189.59							Fee Schedule																													230.58							Fee Schedule																																															
ZIMM NARROW SCP PLATE 5  HOLE	278	RC						Both			256.2	115.29	115.29	230.58		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	189.59							Fee Schedule																													230.58							Fee Schedule																																															
ZIMM NARROW SCP PLATE 6  HOLE	278	RC						Both			290.85	130.88	130.88	261.77		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	215.23							Fee Schedule																													261.77							Fee Schedule																																															
ZIMM NARROW SCP PLATE 7  HOLE	278	RC						Both			290.85	130.88	130.88	261.77		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	215.23							Fee Schedule																													261.77							Fee Schedule																																															
ZIMM NARROW SCP PLATE 8  HOLE	278	RC						Both			290.85	130.88	130.88	261.77		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	215.23							Fee Schedule																													261.77							Fee Schedule																																															
ZIMM NARROW SCP PLATE 9  HOLE	278	RC						Both			290.85	130.88	130.88	261.77		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	215.23							Fee Schedule																													261.77							Fee Schedule																																															
ZIMM NUTS FOR 6.5 CANCELLOUS	278	RC						Both			39.9	17.96	17.96	35.91		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	29.53							Fee Schedule																													35.91							Fee Schedule																																															
ZIMM PLATE 4 HOLE 2358-01-04	278	RC						Both			4259.85	1916.93	1916.93	3833.87		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	3152.29							Fee Schedule																													3833.87							Fee Schedule																																															
ZIMM PLATE 6 HOLE 2347-17-06	278	RC	C1713	CPT				Both			1443.75	649.69	649.69	1299.38		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	1068.38							Fee Schedule																													1299.38							Fee Schedule																																															
ZIMM SEMI TUBULAR PLATE 3 HOLE	278	RC						Both			111.3	50.09	50.09	100.17		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	82.36							Fee Schedule																													100.17							Fee Schedule																																															
ZIMM SEMI TUBULAR PLATE 4 HOLE	278	RC						Both			121.8	54.81	54.81	109.62		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	90.13							Fee Schedule																													109.62							Fee Schedule																																															
ZIMM SEMI TUBULAR PLATE 5 HOLE	278	RC						Both			124.95	56.23	56.23	112.46		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	92.46							Fee Schedule																													112.46							Fee Schedule																																															
ZIMM SEMI TUBULAR PLATE 6 HOLE	278	RC						Both			132.3	59.54	59.54	119.07		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	97.9							Fee Schedule																													119.07							Fee Schedule																																															
ZIMM SEMI TUBULAR PLATE 7 HOLE	278	RC						Both			141.75	63.79	63.79	127.58		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	104.9							Fee Schedule																													127.58							Fee Schedule																																															
ZIMM SMALL EPIPHYSIS LEFT T PLATE	278	RC						Both			222.6	100.17	100.17	200.34		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	164.72							Fee Schedule																													200.34							Fee Schedule																																															
ZIMM SMALL EPIPHYSIS OBLIQUE RIGHT PLATE	278	RC						Both			222.6	100.17	100.17	200.34		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	164.72							Fee Schedule																													200.34							Fee Schedule																																															
ZIMM SMALL EPIPHYSIS RIGHT T PLATE	278	RC						Both			222.6	100.17	100.17	200.34		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	164.72							Fee Schedule																													200.34							Fee Schedule																																															
ZIMM SMALL EPIPHYSIS T PLATE	278	RC						Both			222.6	100.17	100.17	200.34		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	164.72							Fee Schedule																													200.34							Fee Schedule																																															
ZIMM SMALL FRAG T PLATE 2454-50-03	278	RC						Both			280.35	126.16	126.16	252.32		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	207.46							Fee Schedule																													252.32							Fee Schedule																																															
ZIMM SMALL FRAG T PLATE 2454-53-03	278	RC						Both			280.35	126.16	126.16	252.32		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	207.46							Fee Schedule																													252.32							Fee Schedule																																															
ZIMM SMALL FRAG T PLATE 2454-56-04	278	RC						Both			280.35	126.16	126.16	252.32		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	207.46							Fee Schedule																													252.32							Fee Schedule																																															
ZIMM SMALL FRAG T PLATE 2454-68-05	278	RC						Both			280.35	126.16	126.16	252.32		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	207.46							Fee Schedule																													252.32							Fee Schedule																																															
ZIMM SMALL FRAG T PLATE 2454-75-05	278	RC						Both			280.35	126.16	126.16	252.32		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	207.46							Fee Schedule																													252.32							Fee Schedule																																															
ZIMM WASHER FOR 3.5	278	RC						Both			39.9	17.96	17.96	35.91		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	29.53							Fee Schedule																													35.91							Fee Schedule																																															
ZIMMER 2.0 DRILL 4806-100-20	278	RC						Both			169.05	76.07	76.07	152.15		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	125.1							Fee Schedule																													152.15							Fee Schedule																																															
ZIMMER 2.5 DRILL 4806-110-25	272	RC						Both			169.05	76.07	76.07	152.15	109.88							Fee Schedule		125.1							Fee Schedule																													152.15							Fee Schedule																																															
ZIMMER 2.7 DRILL 2360-205-27	272	RC						Both			539.7	242.87	242.87	485.73	350.81							Fee Schedule		399.38							Fee Schedule																													485.73							Fee Schedule																																															
ZIMMER CORTICAL 4.5 2306-18	278	RC						Both			34.65	15.59	15.59	31.19		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	25.64							Fee Schedule																													31.19							Fee Schedule																																															
ZIMMER CORTICAL 4.5 2306-22	278	RC						Both			34.65	15.59	15.59	31.19		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	25.64							Fee Schedule																													31.19							Fee Schedule																																															
ZIMMER DERMA CARRIER #00-2195-012-00	272	RC						Both			36.75	16.54	16.54	33.08	23.89							Fee Schedule		27.2							Fee Schedule																													33.08							Fee Schedule																																															
ZIMMER DERMA CARRIER #00-2195-013-00	272	RC						Both			105	47.25	47.25	94.5	68.25							Fee Schedule		77.7							Fee Schedule																													94.5							Fee Schedule																																															
ZIMMER DERMA CARRIER #2195-13	272	RC						Both			102.9	46.31	46.31	92.61	66.89							Fee Schedule		76.15							Fee Schedule																													92.61							Fee Schedule																																															
ZIMMER HEMAVAC EVACUATOR #00-2568-000-10	272	RC						Both			90.3	40.64	40.64	81.27	58.7							Fee Schedule		66.82							Fee Schedule																													81.27							Fee Schedule																																															
ZIMMER WOUND DRAIN. DEV.#00-2560-000-10	272	RC						Both			185.85	83.63	83.63	167.27	120.8							Fee Schedule		137.53							Fee Schedule																													167.27							Fee Schedule																																															
ZINACEF 1.5 GM/100ML NS	636	RC	J0697	CPT				Both			48.11	21.65	2.11	43.3		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	35.6							Fee Schedule		2.11							Fee Schedule		7.83							Fee Schedule											43.3							Fee Schedule																																															
ZINC 945 PLASMA ROYAL BLUE TUBE SP INSTR	301	RC	84630	CPT				Both			63	28.35	10.12	56.7	10.12							Fee Schedule		12.65							Fee Schedule		11.73							Fee Schedule		11.39							Fee Schedule											56.7							Fee Schedule																				11.39							Fee Schedule																				
ZINC GLUCONATE 50 MG TABLET	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
ZINC OXIDE 20% OINT 30GM TUBE	250	RC	A9270	CPT				Both			7.41	3.33	0.01	6.67	0.01							Fee Schedule		5.48							Fee Schedule																				2.04							Fee Schedule		6.67							Fee Schedule		2.35							Fee Schedule		1.9							Fee Schedule											2.35							Fee Schedule		1.9							Fee Schedule		
ZINC OXIDE 20% OINT 60 GM TUBE	250	RC	A9270	CPT				Both			7.41	3.33	0.01	13.1	0.01							Fee Schedule		5.48							Fee Schedule																				11.39							Fee Schedule		6.67							Fee Schedule		13.1							Fee Schedule		10.59							Fee Schedule											13.1							Fee Schedule		10.59							Fee Schedule		
ZINC PASTE 4OZ MSC092ZP04	270	RC	A6250	CPT				Both			6	2.7	0.03	5.4	0.03							Fee Schedule		4.44							Fee Schedule																													5.4							Fee Schedule																																															
ZINC PROTOPORPHYRIN 948	301	RC	84202	CPT				Both			120	54	12.75	108	12.75							Fee Schedule		15.94							Fee Schedule		14.78							Fee Schedule		14.35							Fee Schedule											108							Fee Schedule																				14.35							Fee Schedule																				
ZINC SULFATE 220MG CAPSULE	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
"ZINC, RBC 6354"	301	RC	84630	CPT				Both			63	28.35	10.12	56.7	10.12							Fee Schedule		12.65							Fee Schedule		11.73							Fee Schedule		11.39							Fee Schedule											56.7							Fee Schedule																				11.39							Fee Schedule																				
ZIO MONITOR APPLIC. 7-15 DAYS	731	RC	93246	CPT				Both			200	90	11.81	481	150							Per Diem		148							Fee Schedule											11.81							Fee Schedule		14.35							Fee Schedule		180							Fee Schedule		16.5							Fee Schedule		13.35							Fee Schedule		481							Per Diem		16.5							Fee Schedule		13.35							Fee Schedule		
ZIO MONITOR APPLIC. UP TO 7 DAYS	731	RC	93242	CPT				Both			200	90	11.81	481	150							Per Diem		148							Fee Schedule											11.81							Fee Schedule											180							Fee Schedule																				481							Per Diem																				
ZIOX OINT-30GM	250	RC	A9270	CPT				Both			277.2	124.74	0.01	249.48	0.01							Fee Schedule		205.13							Fee Schedule																				11.39							Fee Schedule		249.48							Fee Schedule		13.1							Fee Schedule		10.59							Fee Schedule											13.1							Fee Schedule		10.59							Fee Schedule		
ZIPRASIDONE (GEODON) 20MG/ML  INJ	636	RC	J3486	CPT				Both			75.6	34.02	5.77	68.04		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	55.94							Fee Schedule		5.77							Fee Schedule																				68.04							Fee Schedule																																															
ZIPRASIDONE HCL 20MG (GEODON) CAPSULE	250	RC	A9270	CPT				Both			28.35	12.76	0.01	25.52	0.01							Fee Schedule		20.98							Fee Schedule																													25.52							Fee Schedule																																															
ZIPRASIDONE HCL 40MG (GEODON) CAPSULE	250	RC	A9270	CPT				Both			27.56	12.4	0.01	24.8	0.01							Fee Schedule		20.39							Fee Schedule																													24.8							Fee Schedule																																															
ZIPWIRE ANGLE TIP M0066802061	272	RC						Both			121	54.45	5.21	108.9	78.65							Fee Schedule		89.54							Fee Schedule																				5.6							Fee Schedule		108.9							Fee Schedule		6.44							Fee Schedule		5.21							Fee Schedule											6.44							Fee Schedule		5.21							Fee Schedule		
ZIPWIRE STRAIGHT TIP M0066802051	272	RC						Both			121	54.45	54.45	108.9	78.65							Fee Schedule		89.54							Fee Schedule																													108.9							Fee Schedule																																															
ZITHROMAX 200MG/5ML SUSP-15 ML	250	RC	A9270	CPT				Both			85.49	38.47	0.01	76.94	0.01							Fee Schedule		63.26							Fee Schedule																													76.94							Fee Schedule																																															
ZITHROMAX 250 MG	250	RC	A9270	CPT				Both			25.6	11.52	0.01	23.04	0.01							Fee Schedule		18.94							Fee Schedule																													23.04							Fee Schedule																																															
ZITHROMAX 500 MG/250ML NS	636	RC	J0456	CPT				Both			79.54	35.79	1.95	71.59		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	58.86							Fee Schedule		1.95							Fee Schedule																				71.59							Fee Schedule																																															
ZOFRAN 2 MG/ML 20 ML VIAL:PER ML	636	RC	J2405	CPT				Both			40.32	18.14	0.09	36.29		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	29.84							Fee Schedule		0.09							Fee Schedule		7.86							Fee Schedule											36.29							Fee Schedule																																															
ZOFRAN 32 MG/50ML (ONDANSETRON) IVPB	636	RC	J2405	CPT				Both			66.15	29.77	0.09	59.54		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	48.95							Fee Schedule		0.09							Fee Schedule		7.86							Fee Schedule											59.54							Fee Schedule																																															
ZOFRAN INJ 4MG/2 ML (ONDANSETRON HCL)	636	RC	J2405	CPT				Both			15.75	7.09	0.09	14.18		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	11.66							Fee Schedule		0.09							Fee Schedule		7.86							Fee Schedule		1.89							Fee Schedule		14.18							Fee Schedule		2.17							Fee Schedule		1.76							Fee Schedule											2.17							Fee Schedule		1.76							Fee Schedule		
ZOLEDRONIC ACID (ZOMETA) 4MG/5ML IV	636	RC	J3489	CPT				Both			3441.82	1548.82	0.08	3097.64		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	2546.95							Fee Schedule		3.46							Fee Schedule											0.09							Fee Schedule		3097.64							Fee Schedule		0.1							Fee Schedule		0.08							Fee Schedule											0.1							Fee Schedule		0.08							Fee Schedule		
ZOLEDRONIC ACID 4MG/100ML IVPB	636	RC	J3489	CPT				Both			648	291.6	0.08	583.2		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	479.52							Fee Schedule		3.46							Fee Schedule											0.09							Fee Schedule		583.2							Fee Schedule		0.1							Fee Schedule		0.08							Fee Schedule											0.1							Fee Schedule		0.08							Fee Schedule		
ZOLEDRONIC ACID 4MG/100ML PREMIX	636	RC	J3489	CPT				Both			648	291.6	0.08	583.2		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	479.52							Fee Schedule		3.46							Fee Schedule											0.09							Fee Schedule		583.2							Fee Schedule		0.1							Fee Schedule		0.08							Fee Schedule											0.1							Fee Schedule		0.08							Fee Schedule		
ZOLEDRONIC ACID 4MG/5ML VIAL	636	RC	J3489	CPT				Both			308.58	138.86	3.13	277.72		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	228.35							Fee Schedule		3.46							Fee Schedule											3.36							Fee Schedule		277.72							Fee Schedule		3.87							Fee Schedule		3.13							Fee Schedule											3.87							Fee Schedule		3.13							Fee Schedule		
ZOLEDRONIC ACID(RECLAST)5MG/100ML PREMIX	636	RC	J3489	CPT				Both			3150	1417.5	3.13	2835		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	2331							Fee Schedule		3.46							Fee Schedule											3.36							Fee Schedule		2835							Fee Schedule		3.87							Fee Schedule		3.13							Fee Schedule											3.87							Fee Schedule		3.13							Fee Schedule		
ZOLL DEFIB PADS ADULT #8900-4003	271	RC						Both			110	49.5	3.13	99	71.5							Fee Schedule		81.4							Fee Schedule																				3.36							Fee Schedule		99							Fee Schedule		3.87							Fee Schedule		3.13							Fee Schedule											3.87							Fee Schedule		3.13							Fee Schedule		
ZOLL DEFIB PADS PED #8900-2065	271	RC						Both			109	49.05	3.13	98.1	70.85							Fee Schedule		80.66							Fee Schedule																				3.36							Fee Schedule		98.1							Fee Schedule		3.87							Fee Schedule		3.13							Fee Schedule											3.87							Fee Schedule		3.13							Fee Schedule		
ZOLL PADS FOR COMPRESSION #8900-0214-01	271	RC						Both			208.95	94.03	3.13	188.06	135.82							Fee Schedule		154.62							Fee Schedule																				3.36							Fee Schedule		188.06							Fee Schedule		3.87							Fee Schedule		3.13							Fee Schedule											3.87							Fee Schedule		3.13							Fee Schedule		
ZOLPIDEM 10590 SERUM	301	RC	80299	CPT				Both			184.8	83.16	13.42	166.32	13.42							Fee Schedule		18.64							Fee Schedule		19.2							Fee Schedule		18.64							Fee Schedule											166.32							Fee Schedule																				18.64							Fee Schedule																				
ZOLPIDEM 5MG (AMBIEN) TABLET	250	RC	A9270	CPT				Both			6.3	2.84	0.01	5.67	0.01							Fee Schedule		4.66							Fee Schedule																													5.67							Fee Schedule																																															
ZONISAMIDE 100MG (ZONEGRAN) CAPSULE	250	RC	A9270	CPT				Both			8.4	3.78	0.01	7.56	0.01							Fee Schedule		6.22							Fee Schedule																													7.56							Fee Schedule																																															
ZONISAMIDE 37852 SERUM 1 ML	301	RC	80299	CPT				Both			99.75	44.89	13.42	89.78	13.42							Fee Schedule		18.64							Fee Schedule		19.2							Fee Schedule		18.64							Fee Schedule		18.64							Fee Schedule		89.78							Fee Schedule		21.44							Fee Schedule		17.34							Fee Schedule		18.64							Fee Schedule		21.44							Fee Schedule		17.34							Fee Schedule		
ZORPRIN 800 MG	250	RC	A9270	CPT				Both			1.58	0.71	0.01	1.42	0.01							Fee Schedule		1.17							Fee Schedule																													1.42							Fee Schedule																																															
ZOSTAVAX (LIVE) VACCINE INJECTION	636	RC	90736	CPT				Both			804.3	361.94	361.94	723.87		35	Paid in addition to other negotiated rates for individual billing code only when the sum of the listed individual billing code claim lines is greater than $500.00. Otherwise deny. 				0	Percent of total billed charges	"Rate only applies when calculated under All Other contract terms | No historical remittance data available for this CDM code type under the specified payer/plan, as remittances do not itemize at the CDM level."	595.18							Fee Schedule																													723.87							Fee Schedule																																															
ZOVIRAX	250	RC	A9270	CPT				Both			130.82	58.87	0.01	117.74	0.01							Fee Schedule		96.81							Fee Schedule																				18.64							Fee Schedule		117.74							Fee Schedule		21.44							Fee Schedule		17.34							Fee Schedule											21.44							Fee Schedule		17.34							Fee Schedule		
ZOVIRAX  500 MG/NS 100 ML	250	RC	A9270	CPT				Both			11.55	5.2	0.01	10.4	0.01							Fee Schedule		8.55							Fee Schedule																													10.4							Fee Schedule																																															
ZUMI UTERINE MANIPULATOR 4.5MM ZSI1151	272	RC						Both			54	24.3	24.3	48.6	35.1							Fee Schedule		39.96							Fee Schedule																													48.6							Fee Schedule